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Employee #L{4o <br />Employee Name C6W <br />DATf o /cb <br />(s) (Ml €p twt $H) (F) tsA) <br />Beginnlng 7*7 V 450 <br />Ending a1 s lbb <br />Accident Yes- t'to { <br />Selland Construction, Inc. <br />TOTAL <br />3o'6 <br />Gallonsof Fuel: On-Hwy 41. I off-Hwy--* <br />STANTTIME STOP6 :jb,15 <br />1l <br />lfAccidentwasTrucklTrailerloadeck \Gs-* uo K - <br />",36 <br />DOyyN <br />r,ME <br />. t. .; ,i ; <br />r.4,., ,., <br />....t' :. ' <br />'-'. ':, ",.1't- <br />:. '..'l'.: l '- <br />DstvrN6 <br />. ...":;"':. <br />t. <br />.1,.. ..i, . <br />' .i;:- ' <br />' -..! r :.!. <br />. gQulpft€A,tfJouns <br />Tsnrlgn <br />>t,3oz <br />TRACIOR <br />Wa <br />rir: I ' -;',1:' <br />I r: ,. ' .:'i.,. <br />,,it.l- !.,':,'t.. <br />i. .. .., r:'".' :,.., ,_,...;: .-j <br />):' . t..-j- . <br />rorrL <br />,JOUfiS <br />.. ..:' . <br />t. -:.' <br />': '-.r'i':,.-: <br />PAYNAT6 <br />'i'.',-..":..j <br />, ': ..',. . <br />loAoS <br />{ <br />MATEN$LHAULED <br />b*on.4 3,.+ <br />v <br />'.1ir: r' i.. <br />'.,'-;r.i 'rj: <br />''ti-.:;'.'1;;"" <br />i:)+.. ii i;, <br />t,t-'.'-'-!-:r'i'.; <br />' ''' '.'., ';. <br />,i ;:". .: ' , .'' <br />'r: r'r.. .1 .!. <br />;.-i,:..n' <br />frnlo,- <br />JOg NAfu'IEtoBc <br />Llla4o <br />Ernployee Signature Foreman Appr*rval -\ttr