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Uep.of Roaou as Reoyolfng and R000vary <br /> CA Comprehensive Trip Log and Receipts 10002 P�,Bdii'1260,Saaratnento,CA05M.-1260 <br /> ca��BCycle A nn P L 1 3 ' a + Com -retie sive Tri Number <br /> Elela orCOJerNe l8 x'k t r �/((� �T`acSS�'-'- <br /> cawacypd2ptpn9lINSTRUCTIONS ON BACK OF PART 2 p0 NOT PE STAPLE OR DUPLICATE <br /> 13Y In ICA 06mprohorillve.71rip Log and pad olpt,th a elan a r(o)r6qu'oat ifis(IT19 formation provided on this form VIIII be oanildftod Confidential,proprietary and trad6fidorat.1no0o anceWW/T!11o,4400n,f!eollon� <br /> 17041 it o•q,It n request 11 mstlo lad dloola W ro of(hfa inlotmolion,CeIR6oyala will aonlact iho slgnor(a)of Ba rin <br /> title form al thf addro• d tataphano rnimber prIeAded on thts form or raeeip6 <br /> ' ayell Mauterpddress {�r�v � 1�('1.� - <br /> A --t <br /> # F Fb Business Name <br /> Address <br /> 4 _• '. City,State'and ZipD" <br /> ti nn .�` trtia Common <br /> Q Carrier <br /> I Wily undgr penalty of paqury UP at the lewa of the Slate a$a0tomin that the Inldrattiuon provided abovq to uua.snd ooneol.In addition,!am awara that.falstfWalldn of t}da Informallon may result to au peaelon,revontlon,or deNui al mnowat of <br /> the WaiveTaoHaylorRoll Imam purauanitoPubllaResources Code'seollon42080and'may rosulllncivil penalties up6 26,000Per day,,parViolaInoroanhiIM110ponalVmvp.to$6,000Pelf Vale lonper day ae'dmcdbedlnPpblldResources <br /> Code seallon 42982 ¢•' <br /> Mid M <br /> _ Driver's Name(print) Driver's-Signature Date <br /> Comprehensive •a <br /> Numb •.a Information Facility Tire� a aProgram ID <br /> 6054565 <br /> as a ori <br /> V7, YPOIlity.Telephon�N(IM er+", <br /> .Hauler Tire Progeain:ID /• itensuflixi ' x ,. •a F.„ ! <br /> I- VICF�a �o• r <br /> it <br /> +c <br /> Fa <br /> }� ,,( `Jf ryr{^e:a t •,T,rr ` 1� r�-,7i s , <br /> eil •f�utnoss <br /> g7G=' Vj�,gt'J,�e'•�`„�'1,.�'Y' F'y '\ a.'�{••' ",{•�',.' 1. <br /> ��a�� �• � '�!'t� ,.� Y � _ 'f [{'tn� •Nal»e/A '(ress'y! ' <br /> *Se.Tr ,,4,'n .r`f+"�sf•� ,,'l'. '. Y'1?Y.ya� y,State 4 d 4.o. <br /> y y Hauler Name �..�:' .,s :r,u:, •� ,,.Cit. <br /> . l.-. r•`I .I� +..<Il' .1,1�1t1'J, li.'it:{�`�. i. v '�.i l+' •i� .. <br /> Ici ',Jj 1 I rYi I ++ <br /> `{ Stump or Lal-oI 0(t <br /> cV <br /> 1!V,,_W4ej1 <br /> l Sarna a Hauler�_�t;iF YY:lfr."'. ' I CERTIFY THAT UNDER PENALTY OF P RJURYOFTHE-'v"a" . } Y '+X.+�.'`rr;2•Elt � (AYIB 9FTH8 BTATB OF bALIFO�iNIA IIATTHE <br /> INFORMATION PROVIDED AWE;3T!t EANGC6R ECT I <br /> ( P <br /> Compvchensive Trip Log Information Facility Tire Program Via <br /> 6:054565 __ , - � _ <br /> tit <br /> Hauler Tare.Pro ram ID "S to i _ i= t,+ r r# Fp lit T le hpn N et <br /> g :/.' i iSuffiX: i <br /> W". <br /> : <br /> 4�.�a-�r. z'i' `.rTa^t' i;i.�ir.:4..�.. :�i`�."• `] •'--!•,. �'� <br /> _*�'` -c•,.fi�t?kfi=�;��� � r,.��-,!>}�� ,_:I� � 1= tli ass i { <br /> � r i <br /> 14, N; ttd ross• <br /> n;} soler Name <br /> MVL <br /> kfauler Telephone Number `3 ,,,,, i I /'i. Address Same ag Hauler In)fr I <br /> . ,aPy'+j"-•-`t-'t+' -+ r"R'' ��, 'l i'' t*; ice_ d d !CER'HFYTHAT UNDER P.ENALTY1OFP RJURY DFTHE ' <br /> L.AW$9F THESTATE OF CALIF DMI HATTHE <br /> tr.`3a�.:;•S�c .-�C~�!!"`t?niai+F��.�.:.cx :a.� ,..r, •INFORMATION PROVIDED-A90VE IETft 2ANP CORRE T <br /> Comprehensive Trip Log Numb r Load Information Facility Tire Program ID Site Stiff ix <br /> el <br /> To. E <br /> �MI <br /> 4n't4iy;, Ij}s xt.} , fin r •_ , ttld� <br /> Haitl.�r-T1r�Prcjgrain•:Ip. / ���e Su�F�X <br /> _ ! 5 � k' 1 ,7}� - =..e v+a Lis x f, +r .,,� ♦ c <br /> � <br /> elf.{c$dJ}tat;r-t=;t:ri;�11`--sia cY,Iu!l�;! I, y¢ j� ,.: ' i;;r ��;.���•? t <br /> _ f.}+{:x✓z 1�1, ] ;,,�i•.,Ad..;..r,,iC-n„G[. tr.% <br /> ::7' -�}�?Jr�"�;?r't.r{ilau!r>lc•,7t1'- tifj� - .{,. z.it,( ,���;;;,,���;,? r'��s::a..;. <br /> IF <br /> - ?ll��r N�nfj, ;i::il�;" ,v{i�7 ;4`4 `r'T��;-{ �i,,j. CTSL".-,t �'^r,:•• ;L?t.� rf`�,`! Ott,{:3..!�•:��: �... �.. <br /> t.1'�fz'v. r'4j( �ii'•1 t d Et';. ,f �l . -y,J + +`' } ..t..,•' g a i'�:ul' '�'. ,i,. <br /> ;!•. :st 3e`3:•ta L'a5isR' ..iY•'t,G `ytw E> 7 �" I i ?:i^�i ,(J '4'-y+ )/�', <br /> , i <br /> a +ts`y <br /> rr =�n xyy ��t�,Ti D 3 1• 1 e_.il 5 S <br /> - .MA7I-ONR O DED.AtDOQB, dA��' CGA1IE`tiYi++ r <br />