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it �LIIG t_IdI'D �.){_ti lI i LOCATION 1'1'11) 1003971 '..ft,., PLEASE REMIT TO: 1(1111 N. Vasco Road ?9?33' i:a:3, !H13a 1'.O. Box 83338 Lis crtlynrc, CA 945.51 '" Z. :: :� 1'ltrtland, OR 97283, Redding:verniorc r'e 1(330) '1-- Area (933) 117-0973 TE RECOVERY WEST.INC. 1-877-0LD-T]'RE. ReddinG:lrea (;3(}) �–�.1 60 1" TTaulcr F jGeneratnr -�End Use Facility Invoice Date , l Load Date 9r /� dl� Phone q 11i ''`k"P Customer Name �E1 Q� -a' r. ^ Vz14z nDelivery /, z� Acct q--------------- Site Street Address2&� {T P'•`2.b City� I,- State_ Zi �C DRI I scrnfy th.0 under penally of pcqurp under the lass s if the Stam of(:aliform"that dm in9mn.mun pf-Mcd True and.oacct LI addwun,I atu .^ aware dw falslficauon of this m(enation may result In susperulun,restwation,or demi of ren—al of the lvaste'rue Hauler Registration pursuant w -- Public Resources Code sauon 42760 and may result ut cull penalties up to S25,0(1(1 per day,per siolanon tit adrmnisintive penalties up to Si,lf(10 per —_ siulanon per day as described m Public Resources Crile section 42762. I-lauler Exemption ent ;JLL'4 ' ❑Agnculire �('unint,it(:"recti TRUCK14ULEFI T H TRLfl/' V R/ ELPER MANIFEST 1 ASH E D C TE IMPORT LOC ION t CUSTOMER TPID/ TRIP LOG`1 EXPORT❑ rl LOAD AMOUNT Description 0 TYP A Tlr P T-Y-P Rate Amount 191 Passenger Tires Passenger Tires on rim 1 Manifest Fee 1.50 1.50 Customer Signat Total Amount 1 certify that under pe nalry of pcqury isms r the lacy of tlln State of Calf that the uif6nnauen presided abo%c is tnm and cor j rca In uhtiuun,I am aware slut nlsnic Inn of this mlilrrtutiun mn resu m nnl licnalnes up to S25,n0O perdiv,per solation or ^ a dlllonstratlre licit allies tip to S5,(R)n per s7111amy'.a n1 per das as, (ted m Public lieu maces Code wun 1•1'_76'_ INVOICE C 140785 4 O / 8 1 Electronic Reporting to CIWi1I13: WRW has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program. On behalf of the Customer Iisted on this force. WR\V will ele(arorlicafly transmit to CIWMB all required information from this manifest form when WRNV Is acting as hauler;and is so marked on the front of this form. Confidentiality Claim: *File information provided on Ihis form should be considered confidential, proprietary. and/or tra(ie secret. In accordance with Title 14, CCR, Section 17041 ei.seq, should any member of the public request disclosure of this inforn nation. I request that CIWh1B contact me at the address and telephone number on the front of this form. 11 SEP 2 8 2010 C Count T - Tons sy Y - Cubic Yards P Pounds