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Dept of H4our oe Fleoyoling and RAoovery
<br /> CA Comprehensive Trip Log and Receipts 10002 Po:13pxi269,.8aoratnento,0A989t�-1269
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<br /> X A M P lr E 1 2 3' � � ; ` �INSTRUCTIONS bN BACK'OF PART 2 DO NOT TAPB,'ST , OR DUPLICATE t ��w��i�, � �` _
<br /> 11•IOnlno fhb.CA Compreh.nshre Trlp Loo end Roo•lpf,Ins if9netpj roquogt lhetjfh6lnlofmi9on provided on this toren will b•oonilderad eenlldonllel;preprlNorysod I(nde acro,.in Foaorpsnoo W1th TI1N,%OOAy800llon
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<br /> If a request 1.coed.fordl.olo.w.of Ude Inlormattpp,COMIC ycle Will ognlagtlh0.10nerre)of tills form pt the address and Wephoho number-prpMod on Wls form or wool L I
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<br /> t oer0ty undorPendry of perltrryunlsr lila liWs of the elafo o(CnOfomhi Viet lhi'Inlam.11on Wovldad olsove fa lruo and conooL In addlUon,l am aware that falsification of ibis.Informallon may rasull In auppmsto",rayooallon,or d4nid of ronevial or
<br /> lho Wplp The Naylorflopialr•Ilon pursuant to Pub!lo Resoureoe Cmloasclion 42002 and may raaull M ddl pand0fe up to E 25,N6 poi do,,per vlolalloo or edminlslipltve peAsilbe up to 50,000 por vlolaVon per day as basodbod th Puike Recaurcoa
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<br /> LAWS OF THE 6TATEOF CAl,IFOtNfA NAT THE
<br /> r`=+� 1;1404_00dE �i'"+ Yi'C.:.C_ S:a�C _ _ INFORMATION PROVIDED ABOVE 13. SANDCORREOT, I ,
<br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID SitO SUff iX
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<br /> HaLUer Telephone Number ,, i !r; ;:1fr Address Same as auler rug
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