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01/12/2011 22:27 209824 0 TECA 648 PAGE 02/03 <br /> Toll Fri '866-bJ6-0600/ www.ciwmb., ov/Tires/ <br /> California Integretso wasire Management Board <br /> CA Comprehensive Trip Log and. Receipts i000a P.O.9D7C,259.$eCfPrR4TtO,CA95812-1259 <br /> umber Com rehenslve Trl Number <br /> L09 WOR A <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> By signing OIN CA Cornprohenelve Trip Log and Receipt,the signet(e)request shed the Infomiltlon provided on Mia form will he oonel6•fa0 confidential,proPH•t#7 ena tro69 eBCra6 In ecoordance with T1rIe,t4 COR,eeoaon <br /> 7.1 et..q..N e-quest Is ma0e far dlocloaure of thle IM-11on,the CIWMB will confect the•lgn•f(s)of au rano at the eddr•as and tOlepha"rwmb•r provided on We term or reoelpl. <br /> �. a tt'rlt..'ic;it..'.)t• fIG <br /> i Hauler Address F <br /> Business Name <br /> Address Les Schwab Warehowe Cedte-s <br /> City, State and Zip &6 NW Madras Mghway <br /> PrinEviRa; OR 97754 <br /> r Common <br /> Carrier <br /> I <br /> b bdery aeon may result In suspen$;O-.revtl GOR 0,Genial a renewal r tna <br /> canary under penalty of Perjury under the laws of the State Of CWlTomla mat the infprmedon Dro aides up to$9.000 per violation per day w dea0/bed In PUDIic Resoureee <br /> Nded above ie truo ano correct.In sednlOn,I am aware Nat fe191•cotlon of ro <br /> wv. TH—Ior rtep4etrafiOn Dursuant to Public R"Ourcec Code Section 42950 and may reeult In CIA penalti08 UP 10$2t5 ,per or admin'i Vail-p <br /> iro <br /> Code 80edon a2962 <br /> D er'S Name print r'B.Sig re Date <br /> !��w Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> jj 3585533 -- C aoo [1.110 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> 0004ea 0000000 <br /> ;:,.s�rn:d <br /> ' i',i'.I ;<:;is=' .;1 C'_I 9 <br /> Hauler Name <br /> Les Sc ivV68.b arr! ar Lr•I.c)i,:`,. <br /> Hauler Telephone Number Address Same as Hauler <br /> {� I CERTIFY THAT UNDER P@NALTY OF PoLIuRY OF THE <br /> — — L)47_ � LAWN OF THE STATE OF CALIFORNIA THAT THE <br /> [1 VROVWEO AB D GO _cT. <br /> �y • • _ •• _ <br /> 3585533 -_ � -oo-aao11a-aa <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> a.00-0000aa <br /> l=a�Elit�216141 <br /> q1 01 IL <br /> 64 4 ■rv(t;�. "tS1{v1•,are,;,%Ip <br /> Hauler Name <br /> I��S swan Starr.; or L.atTa!is Y"., <br /> Fla, <br /> - Q Address Same as Hauler rnro J <br /> Telephone Number I.CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 5�r�* _ !a7 j y a](� LAWS OF THE BTATII OF CALI►OIO m THAT THE <br /> i 4 'EMC INFMWATION pROVIOW ARWE IS TRUE AND <br /> ■ • • •• •' • • • • - ■1' <br /> 3585533 -- A . 13110 1111 [10-0 [1 <br /> Hauler Tire Program ID / Site Suffix r Facility Telephone Number <br /> Wil- , :�-r ,1!,4 e <br /> R- <br /> H?uler Name 'V <br /> C_ <br /> Lee Ser3wah ::s .���.�r.; �4 <br /> Lee3 <br /> Y <br /> Hauler Telephone Number I Address SarOF <br /> HauT <br /> � cERnrY Trynen r'unPENALTY of P ✓uRr OF <br /> me r <br /> — 541-447 <br /> ��^��� `� /A LAWS OF The STATE OF CALFORNIA THAT THE <br /> L.�C 6 NP.R"TION DRO Y TN eNO CO <br />