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t ' Aept,of 118sotiroes,fleoyolln0 aild Reocive 1 <br /> CA Gom�prehe.nsi�e Trip Log and Receipts .'10002 P.O.Box 1298,seoramdnto,WW12-1260. <br /> Cal�,e�, ale .E X Ah� '� 1 . s Gort� rehensive Tri :Number <br /> cr.r.e'o,uoyr � <br /> mi 7 ., k; pa 7f��_ •� <br /> ca f(le*yeh2Rl��fp�l(1i$TRUGT(ONS ON BACK DEPART 2 DO NOT TAPE STAP(_�OR DUPL(CATB `° ��' �Ui "' <br /> / <br /> r` By dpntnQ thlo <br /> .,ICA 6..&t to enaivo Mp LoB and Raoelpr,Ru dpnorlel raquo9l that Itso IntonnollonproVlded on shla corm will ba aonelderatt amllWonllol,propdelary qnd trado aocroh In goodNenaeriltls TIIte,4q GOR,6.011.n d <br /> 17011 e1 uq.,Ifrregw at la mads for dieoloqure of lhlq lnformelloh,Uftoyole.vint oantaoLCto slpnerta of thla.form.ot!tie q{{dr*aa and;elephon*.nupipor provldod gnlh4lonn or regelpl. j <br /> Hauler Address �^- . .' -� CO, <br /> iota <br /> •� cF <br /> Business Name <br /> >,�' ,L;e.p.�:i,,9„y'. �•i±i�••',aOfei�,��;°-� ;,°l'I�M � Address <br /> rbCl tyStat <br /> State and zinf <br /> i <br /> Common 1 +��y <br /> o r L_ <br /> .......•,� Carrier <br /> I oadlty undor pen*Ily of penury under thl leWs n1 the Blale orealllomla that ilia Information provided above 1,fru*knd corrool,In addtllon,l and MAUS that faldBoallon of INS Information may result In au,pantl9n,revdogUon,ar tlentat of TOA!vel of <br /> •IhaYfuleTsoHaulerR*atetrallonpurcwinlloPuWloRoaouroa,Godo aoolton42060andmayreautllnciilpenellIs.uplgS2G,0o0p:::OZ�,: on or.erLninlebellve,penalllmuptoS5A00petNolalbnparAayeadeacrlbodidpuhBOR�aaurd*9 <br /> Code qq pohd2 2rjo <br /> � <br /> Driver's Name( rh4t) Driver's Signature Date <br /> s• <br /> 1p Log <br /> Load Information Facility TW,Program ID Sitia Suffix <br /> - <br /> i r M° <br /> 6054558 , <br /> p- (; 1i,, , p ' �;�� Dopno <br /> Un <br /> .fir, �1 <br /> Hauler TirePrograrri[D-f 7,'sito-sattlx ''" r r ,:; ` 'J �r?r; i Teiephorle'INu.tppep <br /> �. +1�.„,,' •I' .: F� ani 'i�c,�,.,. ,,. :r <br /> F]' U1 L i <br /> �,4E..s'lj f•�' tG .i- •7e r� 7 .1 l,+.� ... - -t;1. 1•'})i'��1 ' <br /> r';�` r. >,- 1 ne/A�Itleess ;z• <br /> o <br /> i1 <br /> Haulol'Na f' =rte•«;. �4_ ..x s <br /> ( Ly,sfal;B 1t1(j'LI 1 <br /> t�� �i�'7�, :f.J. .i :,I .t�;:'-r; �,..tl' i`�•r I -. ' •� IS. •t., '• i <br /> ' :iamp or Labol(lit <br /> 'Hauler Telephone er , { j g Address Same asHauler <br /> 3 fa :�,ro•5.:':.. yy,,+r'1.•:" 5w'4r �i,•. rid nitfals <br /> - i �� 7, ;F�e:--�' b':�• IRERTIFY THAT UNDER PENALTY OP PERJuRKOP THE .. i <br /> .QA1JFUIiNIATHA77HE <br /> 1 <br /> a• Comprehentsive <br /> e Log Number Load Information Facility Tire Program ID Site Suffix <br /> �,"B," <br /> 6054558. <br /> d Hauler The Progratn':iD: /. Site:Suffl; "i- } .r fj" °r " ,i,• ci i Tele �totle. (>;i�tt(�e� <br /> ;�' . I � I tYi' .p I. <br /> I <br /> Paci 1�#y{ 1essIT I <br /> SWI © ) yJu.``1�� 'iia ' j`;Y ZJ <br /> Mauler Name ��=.st ? t;r +_>,^ ., .;.CI tits 3 . aY <br /> 4 . •Hauler I Addileas SaTelephone Number N'� '( me-as.Hauler <br /> l � F•' .e `� lJ � 'Intl afs <br /> CP 11PY-THAT UNDER PENALTY OP PERdUIJY.OF THE <br /> �s - ' "� ' i`e' 't',.?• ,,:,• 'c'+ y,r t"'+� .4V. sOF,..TN4PTATP,.0F CALIFORNIA THAT THE I . <br /> 9 '"_ •�5 a�s k`•�m"!�3 { m 1x� h - INFORMATIONPROV(DEOXBOVEIBTRUEAND.C($RH <br /> •,3 '.r.'s..` q!^--aj!!'�'�.rJ !!_ I lyi7.@�lesj"'' 7pi• :sl'I tFrfF`s%.1� F,_,r x:18 _ $�' IN;9 <br /> 1611 <br /> ;M Nfl- <br /> ti k -., ,1 rl':1:'1 Ria°4..,�t° �'•=L•(IS 6� 1 t n1,:i �' <br /> ' f3t is U'I _ r f3 �tt a ,;..re <br /> t��u��� Ville i'YogXahSf)Dj X t <br /> :. 7Ht tic(IIlU IW rttV>iAa1.91�,Ik! �`��� i �',a` fsfV'Ij`ta'Y s.�;t�+�. � ' ��"t*pkg�t� i•s�IylSifi�sfyt��r rn�v ii��7 <br /> r r,s`; • 'ti r 1>:k`p'2, i'tll".�ri1t(nl� 'TrtrLliJt�l 1i'y �,`, -+r> , t <br /> ' '� .••�'� ,.alY ,Ir. ly � i S i � n s�9. 17� y'. a,, <br /> p <br /> `1c...,. .f, -- '---�-['-•-..5.!' r r�s}� +r��Jy' "`•� �.`.fi� ' Fdp•`'t. _ '�!�� '�i 'L _ i t- 6. '1 <.J�'�' T-M,�•+•�?': ''.':: _ <br /> 1�rit'--' <br /> 'yt�t �tk;.� �r`t,i;v LE�1{�"i""f-r J��q,� ii I �� I :[ g '� l ���j�ityt�I f � •;;n.;^ :`I <br /> � r'u%,.i+4. :,�.�•1 Nh '}'+ fk. �1 rte � t ��b �1���1ALI�F,OIi t T AT I t>i,r, � � '��` T!r�C's <br /> ;T"H=i- ...� 44'.-..`kF.'T•... �. ! _. �• :•rxrc=;r.-.:E :+�- .�>i�._..�.�rr✓�:�.s fiOR,�i1'ID�!'RRO E'6.AF10 Ea 1eTA�ANIS�OR'��L�.rs-� .P"•.:, <br /> ,AE+^_�s-,M4sFwtFc�.'lslM3Wh,�'u1^5���as� ,.. .s... •-N-r =i � .", <br />