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RoBi -866-896-MM / Anrr,v�n�r.��� <br /> - - - Ann Dept.of Mesources Her-yfRe <br /> lin9:rld covery <br /> Oa .t000 <br /> A coinprehensive Trip Log and Receipts 2 P.O.P.O.eox1259,Sacramento,CA45II12-1259 <br /> CaIR!CICIe E M[p L f j Comprehensive Trip:Number <br /> r ia'TxyaeYoo(7�lpJINSTRUCTIONS ON BACK OF PART 2 ,DQ N-0Q TAPE. STAPLE OR DUPLICATE 61)C <br /> Ry ssgring Ih18 CA Colniprohmsbe Tnp Lottend Paeolpt.lho sgneilsl request ilhat tite Inrermaltan paouldnd on IM,t m-wle tw cnn:Id Prod co"fidanllal,prnpdalary anti 04,10 h0cset. In aoeordince wItI Tele,14 CCR,9'ectwl <br /> 11041 et aeq„It a request hs made for disdosurs of This Information,CoMmyele tv.1 eanteot the sagncr(s)of thea tam al the addraas end telephone number pro-Mod an this term ar rncaipl. <br /> Vehicle Information <br /> Truck Decal Number Hauler Address <br /> Busfiiess Name <br /> Address'CitStAte arta Zip /� '4 /30�` <br /> License Plate Number State <br /> Common <br /> I eaW y vndf penalty of perjury.,e—1Fo lawn d lire 9laW al CEW-Mita that tha trdnrmofionlpro.i!dod ah—at t—and oarmct.N addt=.I"aware that 131sl9calion of Ih:Irh maucn n y result In sutpensOA rovotallon.or oento of fenewalof <br /> �\the Wasle Tae hauler Reglskalirn ptralnat b Public fteaoLYooa Coi%sac4km 429rX and mar resell In pN8 penallba up to$25.0M per day.per vglsBwl adrnNhYellre P:-h)2,up Io 59,090 per vlddlpn per day as described In PAtlle fWeowcaw <br /> Code sedlon 42842 <br /> Driver's Name(print) Drnrer s Signature Date <br /> Comprehensive Trip Log - Program ID Site SLJffiX <br /> 4596024- �� Pick Up Delivery1 . `i If 1 — <br /> o Facility Telephone Number- <br /> FlaulcrTire Program I[7 / 5it� Suffix <br /> � DATE L� <br /> N a 0 � oo•oo � an <br /> W �.VJholc Tire Count Weight in Lbs. <br /> ►. 31 0 Volume Cubic Yds. Weight in Tons / <br /> E . Y; .., 6 i -, r. <br /> E �Mller Nature <br /> UA/ <br /> R-1—U4;auler'relepbY ne r4tunbel ■ .Rdlii �s Sante a Haut+3r <br /> /t ,e (N/A(or I :BWJIFV THAT UNDER PENALTY OF PERJURYOFTOE <br /> Whole Tires) LAWS OF THE STATEOF CALIFORMA THATTHE rf`dNJ✓1'" � <br /> III uoon•nnnn anrwa to rafts♦uh rYrwrr� <br />