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Comprehensive Trip <br /> Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3085 9 81 B Pick Up Delivery © � ® � —H V] <br /> I Hauler Tire ID / Site Suffix hone <br /> p Program Facility Tele Number <br /> 9 DATE �� / �� / �� •� c' �' r^ <br /> w Whole Tire Count Weight in Lbs. <br /> 000-aoaoa_a © <br /> M a <br /> D f Volume Cubic Yds. g Facility Business 2Z5 Z L-t�eZ t-r-loc <br /> F C� I Wei ht in Tons Name/Address <br /> O City, State and Zipq,�� <br /> ,� r�'uler Telephone Number ( , <br /> Zc- <br /> U ^�/ _ ���_�Z g HEIIII -110 <br /> Stamp or Label OK /L aL / Initials <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE r <br /> for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />