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Ernployee #LSqo
<br />Employee Name %h qAzrC
<br />DATT /r a /<.9
<br />($ t@ {r) (w) (rH} {F) tsA)
<br />Beginnlns odomerc, iaf La f
<br />Endingodom eterili L(h
<br />-
<br />Accident; Yes-_ N" X
<br />Gallons of Fuel; On-Hwy 9-_ Off-HwY-
<br />lfAccidentwasTruckllrailerLoaded: Yes- f'lo X
<br />Selland Constmction, Inc.srnnrlue?)?D rroprrvr€!199
<br />TOTAL
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<br />tAENAMEJOg #
<br />?A{64a
<br />Employee Signalure (-"lc €.'t^A foreman Approval
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