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Tri-c Tire Recycling A .6588 Thys Court Sacramento, CA 95828 Ph: 916-388-2093 Fax: 916-381-57 Jr:`r `2 Fri"i v' Lid Service Address Site# 162 Billirtg Mftss Cust'#BRANNgNTIR1 ,, BRANNON TIRE 1bAT : �_ T 3730 WILSON WAY 3730 WILSON WAY STOCKTON, CA 95201 STOCKTON, CA 95201 Phone: 209-993-2828 JAIME C Contact: 209-993-1358-FRED, Phone: 209-462-5398 Contact: PBOX PICKUP ONLY Pagel / I TPID=1005559 Decal=07-02078 Lisc=9C48165 — Site TPID Sched Date Day Time Clerk Driver Route `P.O.# ,, Order 1001994 12/4/2006 Mon TB 27371 WASTE Driver Notes: PICK UP#53-55 YARD BOX PER JAIMIE Waste Tire Manifest Form for Electronic Data Transfer (EDT) TIRE PROGRAM ID: ( �__ SITE SUFFIX: __(If applicable,from CIWMB Form 647) MANIFEST#: M L-Z / _ ❑ Facility is Tri-C Tire, Inc. as shown on the top of form. TRAILER: El Drop off (if applicable)❑ Pick up# 5 TRUCK#:—/ --STATE:_64 LIC PLATE#-. j -- DECAL#:��-_Q20C DRIVER LICENSE#—c-ad3�9L — (If applicable,from CIWMB Form 648) LOG#: L—- Hauler.Exemption: ❑ Government ❑ Agriculture ❑ LEA Exemption ❑ Common Carrier Part 2: Load Information: Check one:;2-Pick Up ❑ Delivery If applicable,check one: ❑ Import ❑ Export Imp/Exp Location: Load Specifics: Intended Use for Tires: ❑ Retread `t?F�e'cycle ❑ 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- Tota l 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 Check Amount Check# I certify that under penalty of perjury under the laws of the State of Califor imthat the information provided above is true and correct. i � �y Lam— Facility Representative's Name(Print) Facility Repress_ tive's Signature Date Confidentiality Claim(applicable to all parties listed on above):The information provided in Parts I,II,and III of this form should be considered confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information;I 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 the Waste and Used Tire Manifest EDT electronic reporting program.On behalf ofthe customer listed on this form,Tri-C Tire,Inc.will electronically tran4Californithe r uired information from this manifest form. I certify that unde penalty of perjury under the laws of the State oinformation provided above is true and correct.Inaddition,I am aware that falsification ofthis information m suit in suspension,revocation,or denial of renire Hauler Registration pursuant to Public Resources Code section 42960 and.may result In civil penalties 5,000 per dad per violation or administrative pe0 per violation per day as described in Public Resources Code Section 42962. Dries a(Print) Driver's Date ads b