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01/12/2011 22:27 209824 TECA 648 PAGE 03/03 <br /> Toll Frec 66 6-0600/www.ciwmb. ov/tir� <br /> California Mtegraled Waste Managpmtcrd Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 12S9,Sacramento,CA 95612—1259 <br /> Com rehensive Tri Number <br /> E ?E (4?Jul P 'L L, 1 ' 21MUMEE <br /> 3 �= - MMMI_ <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE:STAPLE OR DUPLICATE <br /> c, <br /> By signing this CA Gdmprdhdnsnre ttlp Log and R•rolP4 the slVror{e)request th•e Mo IrVorr•etloO provided on Mle foml wit]!r oonstderod oordidentl•1,proprietary and trade secret.M•ccordence Mtn 7It4,14 CCR,Sec•on <br /> i 7041 at ae•-,U•reuUeet is mod•for dBelosuro of thls 100Wmwilen,the CI WMB Ma contuet th•slgnar(s)or nits torn,at the edd,"s*no Wsphorla ruantrer provided on this form a ryC•ipt. <br /> Hauler Address <br /> Business Name <br /> Address Lips Schwab Warehouse Centws <br /> City, State and Zip 6 NW Madras IhAway <br /> El <br /> Prnrievne, OR TN — <br /> Common <br /> Carrier <br /> I oenYy under penalty of 06JUry under OW)awd of the State of Cgrfornla that a.Infvrnwrion provided nbow Is off,•and Wheel.In addition,I em awaro w1 falsMcatlon or d+b vdgrnslion may peull M su9p4nrJon,rovocatlon,«om;al d renewal or the <br /> Waste Tire r Raglssa•on pursuant l4 PUDOc Resources Code section 42960 and may n=11 In civil p6A&Kie9 Up to 5 25,000 per day,p uiaUOn oe adminlstr2ovItpenalties upto$5,000 Der vioIa000 W day Pi d.W1Jy In Pupllc Resourced <br /> Code train2 f 1\ <br /> ( •� T V <br /> Ives print) Iver' ig t� Date <br /> 3585583 -- c _ ❑ ❑ ❑ FIFI [017101 ❑ - <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> 4 21 <br /> Hauler Name <br /> Address Same as Hauler ` <br /> Hauler Telephon mp®r nrreers <br /> I CETtTIFY THAT UNDlA PENALTY OF PERJURY OF THE <br /> 5 A Y _ 17_ A 7 A P2 <br /> LAWS OF THE STATG OF CALIFORNIA THAT THE <br /> i7FFi X`t �$'�A?CD TION PROVIDEDABOVE IS U ear- <br /> • • - • • • • • • • • • � <br /> 85581 = El El 110 111111-❑ ❑ <br /> Hauler Tire Program ID / Site Suffix Facility:Telephone Number <br /> c " � <br /> 11 � ❑-❑❑❑ ❑ ❑ ❑- <br /> ��i6liP F,L•7i�.��5 <br /> 2 <br /> Hauler Name CMrr,state r.'i 2ip <br /> €&S Schwab �� �or Lzb!e OK' <br /> Hauler Telephone Number dress Same as Hauler rat <br /> I FY T UNL1PJi PlNAI:TY OF DERjURV OF THE 7LA 71AA^1—A73� LAWS or TNM STATrOr CALWORNIA TKATTME <br /> R 541 44 41 ♦ N PROVIDED ABOVE 18 TRITE AND CORRECT, <br /> ' 3585581 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> HaO!er Name <br /> llauier Telephone Numberdress Sarrfe'as hauler iDrners• <br /> ,;, I CERTIFY TUT t!lOEII Pz"A.J Iry Of PERIU OF TMC <br /> .. _.�.+1 e 7 ^447_ A�C} LAWB OF TME STATG OF CALIr-0RNIA THAT THE r r I <br /> \ '� •3S. ^R c7 rHFOR 110!1 OROVIDED ABO - C AND CORFaGT- ' ^- <br />