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7.005 0R;R4 tRFFFRt 7?F)? M4RTTN BROWF.R PAGE 12 <br /> Waste Tire Manifest Faun for Electronic Data Transfer(EDT) <br /> �(A LAKiN TIRE WEST, GNC. <br /> 15305 Spring Avenue (562)602-2752 <br /> Santa Fe Springs,CA 90670 (800)488-2752 <br /> E-Mail:westservice@lakintire.com (562) 802-7564 Fax <br /> CA,HaWer ❑ Generator M End Use Facility f 5 <br /> ADT Manifest# 1000658- 1= �'�— <br /> EDT Trip Log 1000659-__.__._.__ — <br /> ks <br /> TP-r] r. tTRD Regie <br /> Hau>e�ntormatition: ��"Q� FD!'. Facllllry Information: 1 d o vci do �6`115 -41o <br /> Name: LA.% C J Name: t�,7,, U � <br /> Address' .3 �f vi rr luC_l k Addrtasss:q&`1 t ZS S J <br /> rtn. C/AIO 7/n' �'� iry 1 L `�1 ZL 4: CtrV.St2tn Zltl: r r�F 1.-•� e/l l Z,i <br /> - Phone: <br /> Phone: <br /> f�°lSr �'f47j Tire P am ID: I 0 O <br /> llriisle9r3p.NstilBr I } 1. ; Pickup❑Delivery _n <br /> ImportD Export <br /> H"urc,c.�..�t�: G..mnraen ❑ arotctrn,re lFA 6,emnt CI Ccvnmo"G"1rr t 19�t Hsul l-ACallon: <br /> fl APFI�oobtC' � ... -- •> "�O"ir�rt�W��'•'lltt Y ''.q' ..- �r�y <br /> Loadin Order: Count Tires Count Other <br /> —� Tires 12"-18" Wheats l Rims <br /> Tires Delivered/Returned RV Tires 18.5"- 19.5" AHernator 1'Jgres <br /> Truck Tires 20"- 24.5" Starter Cores <br /> Purchase Order Fann 1 Industrial Tires Miscellaneous <br /> Ad ustment Tires Aluminum Wheels <br /> Cash amount Recalls <br /> xOM <br /> Check Amount DEMO <br /> Cheek Number Total TORI <br /> Tire Count Measurement <br /> M Whole Tire Count <br /> Q Cubic Yards Traller Number(s): <br /> LI Weight In LBS License Plate Number.(7 O . <br /> El Wei ht in Tons scare: .� <br /> �iti�lded use rw nres� <br /> �` _ RpCyrleY F'vel. 6, nocal Number <br /> I,,nrMty+het undue r CNMJmIi d P the I fom adlpn @ d 3bovt Is true End twneor in ed Ntbr, am f C el taldflcetlon d <br /> V3 atro"Wwn may MOW M arena.,4nn. .n.au tK d mnawm Of 0%waste Tka FWu101 RVS"EV3n p„r.W to FLOl-Rosouros cone 36COM 42WO and moy <br /> mcJ0.1n ONI pemiue2 uv 16125 000 Der SEN.rw-tolptbn rc adrn!nMhod+en panAbo!JD 10 45.000 PW*140n Det day W dWbed iiz puble Rrnaxcex C)W SeCYon 42@62. j <br /> Driver/Hauler: _ ,, Facility Representativ <br /> Signature: .C? E.— ),'y Signature: r �J <br /> Printed Name`_ - • - —Printed Name: -- - - <br /> CO efidbntlatlty.claw The;nrprnts"n fli,&ided CA ti115 form shoylli hs,considerad. csr8ldaiMul,00060ery.inelbtWOO aobrirc.',Ih of y1, <br /> 'I`ntrl 14.f`CR.-section 11041 et.eeq,eho4l any metobbr iif..lhe-qubllo ragdest dladosllts of this WOMBWn,ll requAo!tftdttCIWM6 d�Mtl'm$stti+6 <br /> addrasa xmd toiephdne huldb r Ab*v4-, I <br /> k(ecaenlc ltepott111O m VMS�I_aMVr 7trF t!IeIw"M w Dow>*m+orym try awm u petadprne in I*VIM*and uIted tt„Man1f1VM-Fpr why <br /> On behor at tro 4uetaner i+hmu on lus fern.L. tkb'Weet.lrc�n N��'ua"aeay immm�kle nbMB d0 iectdr9d q�khq�n tlbm aYe rtl(tnpa�A.G44 hp8 tIQt+1�711d1r1e I •, <br /> LwM t*o YYax1 Ear rb m rnr xa the waste hm liar qyAem tot ibpibrum { <br /> I Atlrlll rrnev <br /> ©/�� d�dd 1Sdirl 3cfI1 14I v_I X69©Z©8�9S S�:ri S©© /9L/6l3 <br />