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4 <br /> �^�• califomis Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts, 10002 P.0.9o:1259,sacraRrentD,CA 95912-1259 ; <br /> E�X AIM P L E1112131Comprehensive Tri <br /> om rehensiveTri Number <br /> 0IW9'!OR(fobs)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 362062 <br /> 7 <br /> I BY 4gning MI•CA r—« e1.. THp lag eM gewlpl,Me elgror(c)reglrecl Mel tlro Inhxmetlon procke0 M Mb 1«m MO W c•rulMrad cmadentlal,praprMury as trade.acnn.In e—d—MM Tele,14 CCR,Seclbn <br /> I IM41 el ee9.,N e bgupl Is msec I«dlKbeun of MIs Inlomutlon.0M CMMS Me CO—Me egn.ric)H lata brie N the edmeea end bbph—«e—p Ided on W/«m«—IPI <br /> Vehicle Informal on Hauler Address <br /> Truck Decal Number .Business Name � Les Schwab Warehouse Centers <br /> F] <br /> L —" H) <br /> ©1�❑ © Address. 646 NXlr Madras Highway <br /> License Plate Number State City,State and Zip Prineville, OR 977M <br /> - <br /> a o o © o El © ©H ❑ Common I <br /> l <br /> I Carrier — <br /> j I under pene0y of pedury under Me laws d 0m slab of Gals nia 0W 0b Inl«ma0on qmw w 80 b me and conen:In I cIn aware Mal IablBullen o101b may rKull fn nW,.re .«danW of rerewal vl ON <br /> Waris T H—W Regioteeon pu—t u,Pudic Resoulcea Cade eecbon 42960 AM may, u4 of Ail were up b S 25.000 per day. «edmMsb•Uve perMMea (5.000 per .W day�es Ne«laed b c R <br /> CM.aemvn4 c>� 0Sa5007� 59 ` <br /> �. Driver's Name print Driver's Signature D e <br /> Comprehensive .. Number Load Information Facility Tire Program <br /> 3620627 -- .0 Fl.Pick Up: E[Delivery' © � ® ® © ©—❑ <br /> FacilityTelephoneTelephone Number <br /> I <br /> Hauler Tire Program ID X'Site Suffix DATE <br /> j5-Whole Tire Count eight In Lbs. <br /> ole <br /> � � g Facility Business <br /> Volume Cubic Yds. Wel ht In Tons Name/Address <br /> 4 1 0 0 2 6 O 1 ❑ ❑ g ,.�Yv rr r/t,,.r-y &L-- <br /> E <br /> a„� <br /> o Hauler Name City;State and Zip <br /> V Les Schwab Stamp or Label OK <br /> a 40040. Address Same as Hauler nNd iC I <br /> Hauler Telephone Number <br /> I�• (N/A for I CERTIFY TNAT UNDER PENALTY OF PERJURY OF THE .I <br /> 1—541—447—4136 whole Tim) uvre OF THE STATE OF cAJFonNu T UT THE <br /> f _ .Wf0gYbT10M,aMYIOEA�a90Y81aTaaIG.M DORRCCr. <br /> Comprehensive Trip <br /> I: <br /> .. Number Load Information Facility Tire Program <br /> I: a <br /> -36.206-27 _■ <br /> 7[Tfck Up ❑ Delivery <br /> Donn <br /> —❑ ❑ <br /> Hauler Tire Program ID / ite Suffix ❑l❑ / 011 11D <br /> Facility Tel one Number <br /> oATEc w ❑Whol Tire Count ❑Wei ;Ir Lbs. aclli Busines 0 0 2 6 4� O ❑ VeCublcYds.❑WeigTons me Address - <br /> E Ci}y;Stat .. d Zip <br /> Hauler Name II <br /> Les Schwab g to <br /> Stamp or Label OK <br /> Hauler Telephone Number: . - ■ .❑ AdiJr "' Same as Hauler mmafa <br /> 1— <br /> 541—447— 136 (N/A for I CETTIEY THAT UNDER PENALTY OF PENURY OF THE <br /> NTOIe llres) LAWS OF THE STATE OFCAL60RNIA THAT THE <br /> INFORMATION PRONDED ABOVE 6 TRUE AND ODRRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 362.0627--ea APick Up ❑ Delivery ❑I ❑ � � � © ❑-� <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE ❑I �I / ®© / El Ed <br /> N 1 LJ a ®o-oo❑o❑© <br /> Lu a Whole Tire Count <br /> Weight In Lbs. <br /> n. <br /> I' i(Vr�4Slry4Ss 4 Cor �! r L' <br /> iP 1 0 10 2 16 14 12 1 1011 i'-E]Volume Cubic Yds.❑Weight In Tons N4'+�j�/Add $ 1 <br /> E Ci t��e n Zip41 <br /> o Hauler Name Si s J oR� , C✓I 9 S�z(52 <br /> v Les $ChwabC000millinou <br /> Stamp or Label OK <br /> Hauler Telephone NumberAddress Same as Hauler RRfDara <br /> 1- I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 541-447-4136 IN yA fa M <br /> NTOforTInLAWS OF E STATE OF CA,UFORUMA THAT TME �• <br /> INFORMATION PROVmED ABOVE 6 TRUE AND CORRECT. J 1 <br />