ࡱ> }|  pbjbjVV 7t<<(**mmmmm8D, 2)LuuuuPPP?9mPPPPPmmuuPFmumuPu@I}x0 q!q!q!mPPPPPPPPPP PPPPq!PPPPPPPPP* 3: MOTOR VEHICLE TRIP TICKETU.S. GOVT TAG NO.PART III. ( For use of Dispatcher, Driver, and User (Continued)PART I. ( For Use of Requesting and Approving OfficesSERVICES AND SUPPLIES PROCURED FROM COMMERCIAL FACILITIESREQUESTED BY (Organization or individual)USERS NAME (Print or type)COSTRehabilitation ResearchITEMUNITQUANTITY (Gallons of Fuel)UNITTOTALOFFICIAL PURPOSE (See note on reverse side of form) GAS RECEIPT IS REQUIREDFuel gallonsTo travel with postdoctoral research associate, Dr. Junping Xin to St Louis to attend the annual meeting of the Society for Neurochemistry. Dr. McGuire and Dr. Xin will be giving a presentation and Dr. McGuire also will attend the ASN Council meetings.. Fuel FORMTEXT      PLANNED ITINERARYFuel FORMTEXT      FROM 1 (TO (EST. DURATION OF STOPFuel FORMTEXT      Total Fuel Added FORMTEXT      4 hrsPREVENTIVE MAINTENANCE SERVICES (Indicate condition of items listed below by S ( satisfactory, or U (unsatisfactory.)FUELBRAKESENGINE CONTROLSCRANKCASE OILCLUTCHFENDERS AND BODYWATERSTANDARD FORM 91. operators REPORT OF MORTOR VEHICLE ACCIVENTTIRES1 First entry must be the place vehicle is to report.LEAKS-GENERALWINDSHELD WIPERSVEHICLE LOADREQUESTED FOR (Date and time)RETURN PICK-UP (Date and time)INSTRUMENTSGLASSTOOLS AND EQUIPMENTHORNLIGHTS AND REFLECTORSREQUESTING OFFICIAL(Signature)APPROVED BY (Signature)Remarks: (Explain unsatisfactory condition of items marked U above; describe any other defects noted while performing before-operation, and after-operation services as outlined in manual M11-101; and in event of accident, make reference to attached Standard Form 91.) PART II. ( For use of Dispatcher, Driver, and UserMotorPool fax # - 708-202-2789 ETRIP OR LOAD RECORDPASS. OR WT.SPEEDOMETER READING Use only E-85 fuel in Flex fuel vehiclesFROM(TO(E85- Locator http://www.e85refueling.com/TO(Or www.afdc.energy.gov/afdc/locator/stations/TO(GAS CARD INSTRUCTIONS:TO(1. Insert gas card as instructed.TO(2. GAS RECEIPT IS REQUIRED.TO(3. It will ask for your ID. This is 6 digits of the license plate number.TIMEDATESPEEDOMETER READING The number is also located on the bottom left side of the gas card.ININ4. Press EnterOUTOUT5. Enter the odometer reading and press Enter.TOTAL TIME OF TRIPTOTAL MILES DRIVEN ON TRIP6. Lift nozzle and select grade. Select low octane / or E-85 for flex fuel vehiclesHOURSMINUTES You will need ID number (license plate number) and odometer reading.7. Begin fueling.This motor vehicle has been used for the official purpose stated above. (See note on reverse side of form.)I have reported all services and supplies procured from commercial facilities, performed the preventive maintenance services listed, and reported any accident.8. Record fuel USAGE and TOTAL in Part III above.Note. - Any officer or employee of the Government who willfully uses or authorizes the use of any Government-owned passenger motor vehicle . . for other than official purposes . . shall be suspendedfrom duty by the head of the department concerned, without compensation, for not less than one month, and shall be suspended for a longer period or summarily removed from office if circumstances(SIGNATURE OF USERS)(SIGNATURE OF DRIVER)warrant (5 USC 78(c)2).     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