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<br /> CA Comprehensive Trip Log and Receipts 10002 P.o.eoE1259,Saenmanto,CA 85812-1259
<br /> Com rehensive Tri Number
<br /> EIXaMP (,. E11123 � - �
<br /> aln,emr(`"°""mo.A INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE 3440259
<br /> BY Mgning IhMC.Cupp t twat-TO,bg.n!R-1p%or.19-q.),.R,wn iM iM InlomNpn p6o,,a an tltla lOnn wln M o jdl d eenlla.ntw,ptOpA.t.ry.M'D.aa..a.l.N...,,d—rIN TtM.14 CCR,S.oewt
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<br /> ehi.001WORM-dillon Hauler Address
<br /> Truck Decal Number �/lr 11 n1Q'.
<br /> Business Name ��
<br /> — HE Address ��IOtIJ a,�)�u—>64.<y�n�,
<br /> 8 City,State and Zip
<br /> License Plate Number State STD C�4iO.Jn
<br /> ❑ a a ❑® Commori ��
<br /> ElCarrier. r'
<br /> I wrdly anew P.-Ity of pMWn ands,dat laws of"stns JP C.0 w.tlu1 au w—aw Wo+ldaa,bo-M.w w,d mn 1.In sadilbnI.m.w.n dui hWft.U-of M hto,—b may tmtl Plaa•tWon�tOvmlbn.d a•,itl of neNMI Of nN \
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<br /> COa.aaalon 420E2 °�"\" n:r.. .- : !�.'_
<br /> l.(►'k '0,81SS07030
<br /> Driver's Name(print) ... . Driver's Signature - Da JU ��
<br /> Comprehensive Trip .. Number LoadProgramr Site Suffix ^
<br /> �J
<br /> a
<br /> --3:4A02-5 9 =- (�~ Pick UO,), Delivery.
<br /> 40 - Facility Telephone Number a►� I/
<br /> Hauler,Tlre.Program lD._/, SIte.Suffix DATEEIR/
<br /> `a ty P
<br /> I
<br /> � RE—
<br /> m w O Wh'oie Tire Count Welghtlin Lbs. .� s
<br /> � � : � IFacUrty Business
<br /> d �; }, y ,:',tom i I, �. t✓i'� atVolume Cubic Yds. Welght In Tons Name/Address-
<br /> E rr City,'State and Zip���. GUI ` •
<br /> o tt,,Hauler Name ,{-� � . . -. (/� y
<br /> C�.�. I 1Ir �` D StamporlabelOKsC4�1!�v .. )
<br /> V ( z)45
<br /> Hauler,Telephone Number a,❑❑❑®❑� ❑ Address Same as Hauler?t rrnahi,.'�
<br /> (N!A for I CERfiFr TWAT UNDER PENALTY OF PEI 1R,OF THE
<br /> T^ �`• .� � 1 tV/'-�y/; {, . - Whole TInB) uYYB OF THE STATE OF CAl1FORNIA TMAr THE :. 177 INFORMATION TATE OF CAU 18 TRUE AND COFRECf. �'�rf
<br /> mprehensive Trip Log
<br /> Load Information Facility Tire Program ID Site Suffix
<br /> •3 4 4 0 2 5 9: -� 6. .1. � .V]Pick Up_ Delivery �:. -M-1. Cha
<br /> �� 01 Hauler Tire Pro ram^ID' L•;Site`Suffix' Facility Telephone.Number
<br /> q ) 9a '.' k
<br /> DATE! �® \ ,
<br /> Baa-000flao ���y
<br /> Xv a O Whole Tire Count 0 Weight In Lbs.- `►��r
<br /> /\ 711 Facility.Business�L
<br /> v 05 152q _ 0 a Volume Cubic Yds.:OWelghtlnTons Mame/Address q �/
<br /> Ox E C",.State and Zip
<br /> Hauler(�N�am-e
<br /> jStamp or Label OK
<br /> x4
<br /> E '1Edress Same(asHaullerTelephone Number ❑❑❑❑❑ � ❑ Ad Hauler.
<br /> / RTIFr.Nr UNDER PEMAIr oc PENRrOf ME
<br /> ..
<br /> mn,a
<br /> -
<br /> -ll whole nA9) .LAWS OF THE STATE OF CAuwRNu MAY Tie
<br /> INFORMAT N PROVIDEO ABOVE 6 TRUE AMD CORRECT.
<br /> C5 Comprehensive • •'
<br /> 3440259 -- A Pick Up Delivery 0 0 D 0 ❑ ❑ 0"00
<br /> d Hauler Tire Site Suffix ID Program ! Facility Telephone Number
<br /> g DATE ❑❑ / ❑❑ / ❑❑
<br /> N ❑ ❑❑_❑❑❑❑❑❑
<br /> w
<br /> M w O Whole Tire Count El
<br /> Weight In Lbs.
<br /> M a racility Business
<br /> E ❑Volume Cubic Yds.❑Weight In Tons Name/Address
<br /> o Hauler Name City,State and Zip
<br /> U a❑❑❑❑❑ ❑❑ Stamp or Label OK
<br /> Hauler Telephone Number � Address Same as Hauler RID/e
<br /> (N!A for t CERTFr THAT UMDER PCIIALTr Df PERRJRY OF TME
<br /> whole Toes) awe Of TME STATE OF CALIFORNIA MAY THE
<br /> IMFORMATON IROVNEO ABOVE TR AMO CORRECT
<br />
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