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0 <br /> i Callfomla Integrated West.IAanagemefit 8"dCA Com rehensive Trip Log and Receipts 10002'. P.O.Bo.1259,Saeremento,CA 959/2-1259 <br /> Eix AIS P E111213 Com rehensive Trip <br /> ri Number <br /> AB'iw(`"'"'Arws)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3 5 9 0 5 76 <br /> SIT slanlrp d,I•CA CPmpn. nsI TAP Lo9.nd FwIA.e1.Y9ner(.)r.R1Iwl IMun er Worin.d•n ProVid.d on MI,Is,n w 9 W c.nYwred conllamtlY,INRM.I•nr W1d e•a...er•L b rmorarW..MN Ta.•14 CCR•Ndlon j <br /> t Tal N wry,N.rgwl Y M&W Is dbcb 0 W.1.(WMW on,d.CnIAAS VIII PPM•ct m.1191g.)of NI.form Y IIW add—and*4ph-nunlllw pr nAl m W.1.rnl a—IPL ' <br /> e c e lntormat an Hauler Address <br /> Truck Decal Number <br /> — a © a Business Name <br /> Address ROMAN TIRES,INC. <br /> S 2 <br /> City,State and Zip 800 LAUREL WOOD ROAD <br /> License Plate Number State _ SANTA CLARA CA 95054 <br /> ® E <br /> ® 2 © ® � ® 0 Carrtier n ' (OQo)990-424Z . <br /> I oW,^ands P—PT of P.HW ands Ns Ipv.of•1.91.w d C.IMamI.IMI Uro Intim—pr~Ym.1.p .rM eorr.Lt In AWMb I.m.wen du1 nwllwlyJppqp o1 Vis bda eon mry molt In Ngp•nsl-—don,s d.W of n n. 1 of W <br /> W.W.T.•H•uW Rs91YnMon PunVY.b Pudk R.sourlas Cod.s.rtlon.2pe0.rd m.Y mull M WM wn.iew up b S 25.000 D.r d+Y•D.r Nd•ticn«.dmn flfere WnYw o 15.000 p.r rb4tlsl W d.T q dralbad N Pu R..ourv. <br /> Al ep 13 0 7 2 715 <br /> Driver's Name(print)/J1 Driver's ' nature '0 5' Date <br /> ProgramComprehensive Trip Log Number Load Information Facility <br /> •n 3590576: -- C Pick Up ' El,Delivery :U0 00 a o 0 0 <br /> n <br /> Hauler Tire Program ID !.-Site Suffix Fac lllty,Telepho a Number <br /> 1 • <br /> w <br /> c0 <br /> w Whole Tire Count Welght9n Lbs. <br /> CIS a <br /> Facility.Busigess <br /> yI I E] Volume Cubic Yds.E]Weight in Tons' ' Name/Address <br /> E Hauler Name City,State and Zip <br /> a00000■o Stamp or Label OK rdrerr <br /> Hauler Telephone Number Address Same as Hauler <br /> i IN/A IOf I CERTIFY THAT UNOpi P[rOLLrY OF <br /> PERJIIR•I OF THE . <br /> Whole TIAs) LAW.OF TAE STATE-•CAL"11"TNAT TM! i <br /> INFORYAl10MPROVIOW"0VE IS TRUEAND ORRECT. <br /> Comprehensive Trip Log Number Load InformationProgram <br /> a .3 5 9 0 5"7 6 -- B - Pick Up Delivery a <br /> Hauler Tire Program ID % Site Suffix DATE Facility.Telephone Number <br /> y _ ooa-®®®aoo Z <br /> wa a Whole The Count'O weight in Lbs. <br /> F achy pusi <br /> o o b S:' — f . g... . MEAN TIRES,INC: ' " <br /> 1-10-1o.1 Q -• Volume Cublc Yds: Weight in Tons ' Name/Ad � EL WOOD ROAD <br /> o 'tjau/nlleryNy�amne42 <br /> N p 1 City,StatS �dq�LARACA,95054_ <br /> N I�)►1 T�It�� t �/ t //,, Stamp or Lebel`DI: gab Ali <br /> U as V <br /> aulerTelephone Number,, ■ 0 Address Same as Hauler, mro,a <br /> �f -�(N/A.fr I cFm9T nui unom rFduLTY of P¢Rn)RY,oF THE <br /> What.TIr..) II�WB OF THE STATE•OF cAL60RMll1 TIYT THE. J��. .. <br /> VV L� 1 INFDRYATON PROVIOEO ABOVE A TRUE AND conREcr. <br /> Comprehensive Trip .. Number • • Information Facility Tire Program ID Site Suffix <br /> 359057.6 -- a1 Pickup . Delivery <br /> 'Hauler-Tire Program II). / Site Suffix Facility Telephone Number <br /> c T DATE / Weight In Loa L <br /> w Whole Tire Count g <br /> ( o Facility��usinP.as <br /> d O S ' 6 1 ❑Volume Cubic Yds. W-19Tonsin Tona . Name/ArXiM1 G:M 0 f CALIF <br /> E city,Sta1EO*42M7A 0 RU G A R 0. <br /> o Hauler Name <br /> LATHROP. CA 95330 � <br /> O1Y1 1N �jQ f11 /)fG I}�1 Stamp 0183 <br /> Hauler Telephone Number /s ■ t/ Address Slrh as Hauler /nrD,n <br /> 1 <br /> Ll clq I (N/A for I CERTFY THAT UNDER PEI TY OF pEAJURT OF TME <br /> I WAOb Tires) Ue'8 OF TME STATE OF CAUFORNIA TIIAT TML <br /> INfORYATpN PROVUJE9 ABOVE IS TAU ANO CORRECT. .�I <br />