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r are California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts -10002 P.O.Bolt 1259,Sacramento,CA 95812-1259 E jX A jM P •L E I 2 3 Com rehensive Tri Number. i Snr.wfaabrnu - - 3 5 8 5 3*4 9- C1 By signing NSI NSis CA CTRIIJCITIONve Tdp es ON BAand Receipt, CK gneOf PAtRT 2than the nfDO NOormation T TAon PE,Ss form TeAP•LE ORidered D�UPp proprietary ��In accordance with Title,M CCR,Section tf 1TO41 at sera.,N e request Is made for disclosure of this Information,the CrWMB will contact the signer($)of this form at the address and telephone number provided on this form or receipt. _ V.ehicle]Iri ormat on Hauler Address Truck Decal Number Business Name' • Address - Us.selwab War&onse'06 s1 9 - City, State and Zip' 646 'NW `Madras Iii,� License Plate Number State 1�T1IleVZIle, OR y Carrier Common I certify under penalty of parjury under the laws of the State o1.Califomia that tlminformation pruvlded above is in*and correct,In addition,I em a—re that falsification of this information may rswN in suspenslon,mvccation,or denial of re—nswal of ON -Waste Tire Hauler twit pursuant to u�lk Resowce Code section 42960 and may result In civil Penalties up to S 25,000 per day,�°i violation edminlstretive penalties up b 55,1100 per vidatlon per day m described b Publk Resources Code"Caton 4296 \ / / .. .. 70 Driver's Nami rint Driver Signature' t Date Comprehensiveto .. .. . Program 3585349 slam—I - � Pick.Up` El"beiiveryl ❑❑ ❑:0 110..❑-❑ - 1 Hauler Tire Program ID / Site Suffix Facility Telephone Number '. DATE ❑❑ � �❑ % ❑� .. _ ' •: c weight:in bs. ❑.❑ ❑ , a❑❑.o.a o_o W a ® Whole Tire Count � g IT t/ �cili y.-Business d -11010121614121 ❑ Volume Cubic Yds.a Weight In`Ong Na Address- (D Hauler Name t Ci r State and Zip:. U. Us Schwab g0 Stamp or Label AK a [:]'Address*Same as Hauler m,uaa HaullerrTelephone Number 1 -541 -447-4136 iN,A,,, I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Thee) LAMS OF THE$TATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE M TRUE AND CORRECT Load Information a 358-5.349 -- B Pick Up � Delivery Facility Telephone Number',: Hauler Tire Program ID / Site Suffix - DATE HM / H[fl ❑ _ .- T Tire ht in"-Lbs. ❑:a :.�. _ �: a J co a ® Whole a Count ,�Weight Es 11010121614121 .Q 1 Q Volume Cubic Yds �Weight in7ons : N I�+�^. r � r�Dn CES .�. o .Hauler Name : '_- STOCKTO ( . Les-.g& 'ab - Q _ (j �) =Stamp of Label c�IC"t 2$20 AddLl Nress ams Hauler J S as Hau e 1/ifara • Number ^J n Hauler Telephone N m p ' (N/A for .f CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 11-541-447-4136 � Whole Tires) LAMS OF THE STATE OF CALIFORNIA THAT THE � ` 7 � • INFORMATION PROVIDED ABOVE isc Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix TRUE AND CORRECT.• i I 3:5'85349 -_ - .AAL , Pick Up Delivery LU H'auler Tire Program ID /: Site Suffix Facility Telephone Number PC` DATE ❑�.�: ❑� / ❑D _ y' 61 ®Whole Tire Count .❑Weight Id.-Lbs. 1 0 02 ,6 4 2 0 Volume Cubic Yds. Weight in Tons Qtai z o Hauler Name City,State and Zip ci IRs SchwabDE 00H-0 fl Stamp or Label OK Hauler Telephone Number a Addiess Same as Hauler initials .. °IERT:r1' F o-. :.:- _-PERJI --—.._ + 1 -54* L-6 -