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Tri-c Tire Recycling 8588'Thys Court Sacramento, CA 95828 1 Ph: 916-388-2093 Fax: 916-3E"16' 22 bpi 1 6: 213 WO Service Address Site# 162 Biliipq#ddress Cust#BRANNON'0 L `y' R BRANNON TIRE 3�7 vv-' ((j1 AY € 3730 WILSON WAY iy LT STOCKTON, CA 95201 STOCKTON,CA 95201 Phone: 209-993-2828 JAIME C Contact: 209-993-1358-FRED- Phone: 209-462-5398 Contact: PICKUP 45' TRAILER Pagel / 1 TPID=1005559 Decal=07-02078 Lisc=9C48165 �a Site TPID Sched Date Day Time Clerk Driver Route , R :# Order# �i 27372WASTE 1001994 1 4/2006 Mon T13 Driver Notes: $725.00 PER TRAILER+$35.00 FUEL SURCHARGE PICKUP ONLY NO EXCHANGE PER JAIMIE v :L X �s Waste Tire Manifest F rm for Electronic Data Transfer (EDT) TIRE PROGRAM gip: SITE SUFFIXr ,L(If applicable,from CIWMB Form 647) MANIFEST#: _ 2 acility is Tri-C Tire, Inc. as shown on the top of this form. TRAILER: Drop off (if applicable) Pick up# TRUCK#: �1(�__S E' LI PLATE#: _.Q�QL_ DECAL#: ` DRIVER LICENSE#�j)$2__J_a (If applicable,from CIWMB Form 648)LOG#: L_ Hauler Exemption: ❑ Government ❑ Agriculture 173 LEA Exemption eloCommon Carrier Part 2: Load Information: Check one:El Pick Up ❑Delivery If applicable,check one: ❑ Import ❑ Export Imp/Exp Location: Load Specifics: Intended Use for Tires: ❑Retread ❑ Recycle ❑Fuel ❑Disposal ¢> Tire Count Measurement: ❑Whole Tire Count ❑Cubic Yards ❑Weight in Lbs ❑Weight in Tons Tire Counts By Type Other Product Counts By Type(if applicable) Passenger: Count Rate Total Other Product A: Count Rate Total Truck: Count Rate Total Other Product B: Count Rate Total Tractor: Count Rate Total Other Product C: Count Rate Total Trailer: Count Rate Total Other Product A: Count Rate Total Other: Count Rate Total Sub-Total l: Count Rate Total Sub-Total 2: Count Rate Total Purchase Order# Cash Amount Chack Amount Check# I certify thatynder penalty of perju under the laws of the State of California th ! infgrmation provided above is true and correct. acility Representative's Name(Print) Facility—Representative's Signa Date Confidentiality Claim(applicable to all parties listed on above):The information provided i ,$ 1,II,and III of this form should be c red confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the,pUti request disclosure of this inform request that CIWMB contact me at the address and the telephone number above. Electronic Reporting to CIWMB:Tri-C,Inc.has been authorized by CIWMB to participate in a Waste and Used Tire Manifest EDT electronic reporting program.On behalf of the customer listed on this form,Tri-C Tire.Inc.will electronically transmit to CIWMB all required i tion from this manifest form. +` I certify that under penalty of perjury under the laws of the State of California that the informati provided above is true and correct.In addition,I am aware that falsification of this F'• information may result in suspension,revocation,or denial of renewal the Waste Tire Haule Regi on pursuant to Public Resources Code section 42960 and may result In civil penalties u to$25,000 per day,per violation or administrative pen a up o$ ,000 p vi I n peril as described in Public Resources Code Section 42962. Driver's a e(Print) ,D,pver5, gnat a to i Oar Data Y k. i a �