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<br /> '- Dept.of Relish gee Rooyollrid and RocovOry
<br /> 02 CA Comprehensive Trip Log and Receipts I0002 RO.BD%1269, a0rAmOnto,CA06812-11,268
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<br /> Com..L .rehnslve 7r1 Number
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<br /> r}rxJ(,aaQ`n1p)INSTRl1C7(0NS ON BACKF PAnT �ry" I
<br /> ( By signing tills CAOorpprohonslvotrlp Log and Raadpt,tha donii.')requost thath11n(srmntlanproyldedon lhb loan W1116e sonaldarydocnh�entlel,pidpnotary and trodq norab In a000 snoe Ylllh Tl tie,t4 con.Seolon' i
<br /> 17041 o1s/q•,Itllmquost is maga Jotd(sNoeure of lhlalnimmmton,CnlRanyole"III cYl ontact the dpnat(1Jof IhU form sl lho addrin and 4elopho qumbu prOv1d10 on lhl•farm or receipt, j I
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<br /> : y.,*1s: .,.�.;9 Hauler Address �S'�' ; . ` 1 G'p�
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<br /> � .: —�r ����- ~, �� •� 1�a �'•�es�, Business Name
<br /> iu' Address O f� �a•t��4-�h�5 %� 0Yz ' I
<br /> ivQ City,$tate and Zip
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<br /> 'L lcFrtlty.u-dx penely al peQyry undo lholmve of the State olCWfornla lhm the lnldrmellon p[avlded abovafslwsand emreel.Inn I am aware Ill¢JpfalQoallon of this lnharnatlotl;a!result ins apenalon,rOYoeailoA,ortlanlal Irsnbwal of
<br /> UiiV{ysie r,HOu•,er Reph, onpW,am to Publ(o Rosoums;Code section 42050 sad may,rowltIn 00 perdQes up to 1126,000 par day,Dor vlplpUgh ,dmtnipl41Frb penalties up to$5,000 per y1ol k1lon per day as dee0dbod Ill P"?ue,nescumes
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<br /> briver's Name(print) —�^ Driver's Ignature Date i
<br /> comprehensi.ve Trip Log Number Load Inforhnation ac Ire; rogram le .1
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<br /> 05: 701 _I LAP
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<br /> iHaillerTire,RYo'graili(Dt C°SiteiSlfficJ it{ ;'': 007.
<br /> 1 (• :�ai�4ty;Telep�}one' lumper
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<br /> IM." Hauler Name ;' ;. .
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<br /> Stamp at'I_at-1e1(.alt
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<br /> S �Il�( - ! r� u. Saneis Hauler
<br /> Sr,Z. aule)•Telephone Number = a„r:.. A ,,:, �,a.`1 Addt'ess
<br /> :+o:rtp.;--•.( ` I CERTIPYTHAT UNDER PENALTYOFPERJURY OFTHE
<br /> �{t�.:;; q •-�'�"''{' '”"''n g+��g LAWS OFTHE STATE OF CALIFORH HE
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<br /> AN i. [' T 4�-:._t?`�.i "(iF'at:SF ':+isru'-'':�:':-- NFO MAT(ON PnOVIDEOAdCVEIS RUEA_I CORRECT _
<br /> t Ecomprehensive / e Load loformationSitI
<br /> 6:05470
<br /> t Hauler Tire Rro;gYam'ID / S1te:Sufftz j�1+s If� =-�7111ti a'��1 ,:1' I E one Nu ! .e ;' I (!
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<br /> Address Same as Hauler
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<br /> Hauler Teloplione'Number
<br /> ICERTIFY THATUNDERPEHALTYO PEnJURYOFTHE
<br /> LAWS OF 1HE STATE OF CAt,IFORt)ATHAI THE I I
<br /> �a " - �•pn �t,.+Y �U?a 3j}q' INFORIdATION PROVIDED AB0VE IB rRUF AND CORRECT. i
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