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<br /> CA Comprehensive Trip Log and Receipts i000z RO,Sox:12�9,s'nramento,0A9SM-1269
<br /> E X A M P (. .E :i 2' � t Comre sive Tri Number
<br /> CalRec�cle K.4011144
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<br /> amuarowor ��`. £ iS
<br /> cldr�yara2dlnalylNST`RUO` IONS ON f3ACK.OF PART 2 D O APE STAPLE DUPI.ICAT :01144 :F S
<br /> ey&i0nin0 this CAOomprohonslva Trip 19,•nd Re%pt,lho dpnei(ef rogaeat that fire Info gall Provided an this farm will be Moldered o alld'enllel,proprloleryand ir•de eooraL In said rice with Ti1fe,.14 COR,teollon
<br /> I• i70i1 el toq.,lf arequop l♦medoLorQlecloture of this lnfotmellonipel(laoyole.wllloontaat th♦♦IOnor(e)of titleformatthe oddre•a and-leto hoM numberprovidod on this fornl or racutpl.
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<br /> C^ r�Go[t=be¢aj1i" ' L 41 Hauler Address
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<br /> I carllfy�undarp♦Wally ofperiury underih•fawe OfUto 8lale of Celifornlalhet rhe lntorma06n providad above is Wo ands frac!.in•ddlUon.lemawer that faldllcelbn of lhla lnformtllos mby.reeult auspenslon,rovocellon,or dmdel Qf:•neural of
<br /> Ih•Waslo Tlro Heulor Ae'latrallon pursuant to Publ(o Roscurcoo Code aecllon A2900 and may result N olve penobles up fo$26,00D p4cdsy,p9rNpla,noredml0leltp0ve'ponaales uplob6,000 per IoloOgn perd�YJS'dssmlbcd In Public nesources
<br /> Code eeolipn A 26e2 - _
<br /> Driver's Name(prfii Driver' Signature Date
<br /> Conloehensive Triplog
<br /> 6054566
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<br /> x +g sX? a d tyL!4Scr S {It¢a I CERTIFY THAT UNDER PENALTY FP.EIJpRYOF THE I
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