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I <br /> ' I <br /> CA Compre, e.nsiue Trip Log and Receipts 10002 RdpBu�11269,SEaremeantc,QAwBi p1va <br /> 2G9 <br /> Cal CIO X A M R 'L :E` 12 3 Com rehenslve TYI umber <br /> eaaaa= . ; t yi <br /> �,wKi,remJnrr,-INSTRUCTIONS ON-BACK OF PART 2 O O TAPE STP 0 DU LIC <br /> : Oy dpnlnp lNe CA Compreh In Tdp Lop and Aecelp6 Na dpnor(q requoat 1ha1 the lnfortn=Iron provided an ILII loltn wGl hd 0onaldo d codlldOplitl,ploprlelarY and(rode 4wal (no YriIh Tllleyl4 OCR,Babllon- <br /> 17041 0l a.qy It a requoat le mpde for dlwloeura of(hh Inforrnellon,C-,Recycle will Contact the elpno'&I 61 this Iolm at the oddraa=do teifphone numhgr provided on lhia,lCrm Of oelpl, f <br /> ry . tl <br /> HaulerAddreas <br /> Business Narne PAY, <br /> Address 1 i <br /> r`•C.� ;,I ��' � R�e.;,�,. :.�,,�..�.. .r�l�� Clry,State andlZip ag <br /> 1 , <br /> 1 <br /> o Common IP i4. +of q, ' 3 <br /> Carrier <br /> Icodil under endl of el <br /> theastation 4290 or fieglsha bnp g1uMl.lO public pecaw 6apl0oddolfeo`lto 4OBO sndm llonyroeW Maolvit ponehlaf ptobove Is true and $2G,000per(day{ioF lolow4ta�lhol or'oldlihIldlon o"InRlr IIJClN.penettlos uplo�B,Wdp rYl'a3ull I'orlon perdoy uodo erA pdNpu6AO Recnu cot <br /> Coda aeolbn 82=02 <br /> Driver's Name(Print) Driv is Signature <br /> ;fir 6 n <br /> 54567 '-- �►�i{ U[a �eli�rery <br /> F ; Hauler Tire a <br /> �t a Program ID: / Stfe:.SufftX' ,,. t, ,';jFac! e e hlo: e' Umber'` <br /> f „t?, � <br /> To l �r le' YQ 'fit 1 <br /> 'dk loia r a"•l.1; ,J�t2j� r,Js ,fiBu.•.4-a'r.... ��.#a., Gt -'•&'� FaFii ty 1:5usrnes iE <br /> x j <br /> - <br /> Hauler Net j',” a� , � , ' '„� i1:01b a/Adtirass: <br /> , ,i a. .;? , State an_cl kip <br /> Stamp o' of K <br /> Hauler Telephone Numb ` _ I dross Aamo s <br /> ass S m Hauler <br /> t� <br /> .'I OSRTrFY THAT UNPER'PENLIF OgERJURY OF TOE <br /> ,y.+�'�.'teos � •twJ�E'.,5tts+. .r , WB <br /> OFTNIt'STATF.OF.GALIFORN) THAT <br /> :INVOMMATICNPRO TOED ABOYEIBT UE AND CORREDt• <br /> • a as <br /> UYID161 <br /> a a a a <br /> ry <br /> n4rN }V �?? �..r.�lT �11fr aA ' ►•i '/� '� I_�I 2 <br /> `�/J,�� <br /> Hauler Tire Program ID`,/ SIte:Suff ki <br /> ` { Telepl)on ►�P ( , <br /> 1Nii <br /> F i it iW�F le Tiro C01tni; <br /> Us ness i <br /> Hauler Name: <br /> r Hauler Telephone Number I + I I <br /> ;;. 3<, r' ( a) I [� Address Same a Hauler <br /> 1 rel <br /> f yf ! i••r+,�}f�v s;,•�?ir?r•:,d�' '„,,.'k.''ai: I� .I,,r v'ti'f I CERTIFY THAT UNDER PfNAl.T1'OF PERJURY OF THE I <br /> C, , T” i}331 .Y"iz A'�z.•`•� ra •, art'•3' 4 .,. THE STATfi OP.GALF NIA ATTtIE <br /> 'INFORAIATIO EANDOORRECT <br /> a e a a s a <br /> a,a e a r <br /> r � <br /> kir:n }/••�� [/�� F�'�•' f.?:;�i' c )�q{ j <br /> �; r,, �� •!q1 FII . � v; t t '{t P:"� 7 { <br /> Hauler'Tire Prog , 11r.Yra <br /> F(ii,1,� i rPua�UI!l��I •'' ,,�_t � ��� i s Ij�.t,,��1 y�3 0 :S V V_iy i �} l , l - <br /> tv 1i rt Y�t�Sl��ll �, � �Perri I�€'I;j I.+i r •' ' {41! � '�p �I; <br /> I�tat�lu�Jari€ifi 'T��; ,4►(; ,� . � i,• �t t , I �,_, 1 <br /> � -r �y,1# +. I,Ifi1 't .r l � t t t.;,ry � 1 �.�, .�7 1 ��.� f t i f1.� t F. ._ •_1 `/`f Yr 1. <br /> 1 l'� .t. � �� � �yx ;�� =� i�'*? A� �ti� ' � „x # d� 7•"'.� t,, <br /> q •-i. f `T•O� +E7Ll t L � $t`�. <br /> x , <br /> a Rob hdflRkDT.. <br />