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Reso ces CA Comprehensive Trip Log and Receipts Dept.of 1259,Sacramento, aud Recovery 10002 P.O.Box 1zss,SaDremerlD;CA 958112-lzss CaIReCyCIe EXAMPLE •1 2 3 _ _ Comprehensive Trip Number sr exydO Mamm 46758,19 t�r'e"'ce"""�INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE By signing this CA Comprehensive Trip Log and Receipt,the signeris)request that the information provided on this torte will be considered confidential,proprietary and'trede secret In accordance with Title,14 CCR.Section 17041 at seq.,H a request is made for disclosure of this Information,CalRecycle will contact the dgner(s)of this forth at the address and telephone number provided on this form w receipt Vehicle Information Truck Decal Number Hauler Address Business Name a L' Address L Schwab Wmehotlse Centers City, State and Zip Cooley Ad. License Plate Number State Bend, OR #n010 o a © aH o a oCarrmiemon I I certify under penalty of perjury under the laws of the Slate of California that the information provided above is true and correct.In addition.I am aware that falsification of this Information may result in suspension,revocation,or denial of renewal of. the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 par day per violation or administrative penalties up to 55,000 par violation per day as described in Public Resources Code section 42962 /rl�s� II/oYk 75802 I«1ST ri Drivil Name(print) Dri�nature Date• j Comprehensive Trip . . Number Load Information Facility Tire Program 467580-2 " C Pick Up D Delivery. Facility Telephone Number � Hauler Tire Program ID / Site Suffix DATE [10 / 00 / a IJ i DaD- DDaDDDo wa ® Whole Tire Count1:1 Weight in Lbs. i Facility Business y11 00"904121 1,013 ❑Volume Cubic Yds. E] Weight in Tons Name/Address I c Hauler Name City,.State and Zip Lies SchwabStamp or Label OK U Q I Address Same as Hauler Hauler Telephone Number _ morals y (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE j �YYIF li'A7Y Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT 7HE _ _ _ INFORMATION PROV DED ABOVE 1S TRUE AND CORRECT... �J r _ Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix 4 6 -- Pick U Delivery SL 7502 B; (�] p ❑ oa © DDDo ® a 0 Facility Telephone Number j j Hauler Tire Program ID' / Site Sluffix / DD / a DATE l O cw ® sWhole Tire Count Wei htinLb . Q Q tttt� I ® $ Volume Cubic Yds. Weight in Tons !��nl:/ cha ,< 9533E J E Hauler Name �tOty$Stte�a�T� o 1�bS I j r,1n�k<A7 3b ULes Schwab a Stamp or L LwC HAddress Same as Hauler auler,Telephone Number Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OFTHE �'3j iii Y1�7i7 Whole Tires) 1AW5 OF THE STATE OF CALIFORNIA THAT THE MATION PROVIDED ABOVE IS TRUE AND CO INFORRRECT. Comprehensive Trip Log Number Load Information Facility Tire Program .•n. Pick Up Delivery ' , 3 5 T — G L11Q 467580 -- A I DDDDDDD y �� D FacilityTelephone Number r 0 Hauler Tire Program ID / Site Suffix DATE aoo- oDaaoao a ® Whole Tire Count [:] i Weight n Lbs. 110 10 0 Q r_ 3 E] Volume Cubic Yd(D ElWeight in Tons .y s. Udd-Q fate anZ o E f Sd Hauler Name I,�}r�r+or� IRs Schwab Stamp or Label OIC U a Hauler Telephone Number ■ .D rn Address Sae as Hauler Initials 000DEOE (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 4 Yii SJAJ•/ Whole Tires) LAWS OF THE STAT_OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.