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I <br /> rd-c TAre Recycling <br /> 1588 Thys Court <br /> ;acramento, CA SS828 <br /> Ph: g16.388.2083 Fax: 916-3815412 <br /> BRANNON TTTZE <br /> BR.ANNON-ALPINE YARD 3730'WILSON WAY <br /> 1624 EAST AVE. STOCKTON,CA 95201 <br /> STOCKTON, CA 95205 <br /> 77 <br /> Contact: Iim <br /> Phone; Contact: Pagel Pagel /1 <br /> PICKUP TICXCET <br /> 7�- NMI <br /> 'i'PiD-1005559 Decal-()6-01100 T.iscr9C48165 <br /> 1107202 6/112006 Ihu ,1,E ' <br /> Driver Notes: $725.00 PER TRAILER 4 ONE 45-EXCHANGE <br /> Nb <br /> Waste Tire Manifest Form for Electrb, "IC Data Transfer (EDT) <br /> TIRE PROGRAM ID; d L O 2 2D SITE SUFFIX o/,(If applicable,from CIWMB Form 647) <br /> MANIFEST M M L Q .:�E_1 Z L4�ectltty Is Tri-C Tire,Inc.as shown on the top of this forth. <br /> TRAILER: D Drop off Q(!f ap fi le)� # <br /> O STATE:g-Q LIC PLATE#:� ._ DECAL #: (--0-/–L2� <br /> TRUCK : —_ <br /> DRIVER LICENSE#—_—_---- <br /> (if applicable,from CIWMB Form 648)LOG M I_—-———_ —---- <br /> iiauler Exetrnptlon: ❑ Government fXAgriculturIi y La c ble,check one:O Import C3 Export ImP/I:xp I-ocation: <br /> Part 2;Load Information:Check one: ick Up D Deer <br /> {ivery if app <br /> Load Specifics: Intended Use for Tires: D Retire Recycle ❑Fuel D Disposal <br /> Tire Count Measurement: D Whole Tire Count ubic Y4Ms CI Weight in Lbs a Weight in Tons <br /> Tiro Ccurtts By YYPe Other Product Counts By Type(if applicable) <br /> Other Product A: Count Rate Total_! <br /> Passenger Count Rate Total <br /> ttael,_ Other Product 13: Count Rate Total <br /> Truck: Count Rate Other Product C: Count^ Rate Total <br /> Tractor. Count Rate Total Other Product A: Count Rate Total <br /> Traitor. Count Rate Total <br /> Other. Count Rete Total <br /> Sub-Total 1: Courtt __ Rata Total__ Sub-Total 2: Count Rate Total <br /> Purchase Order# <br /> Cash AmountCheck Amount Check# <br /> I certify that under penalty of perjury under the laws of the State of Califomla that the information provided above Is true and correct. <br /> Facility Representative's Signature Date <br /> X,,nacility Representative's Name(Print) Meta and/ortrade <br /> gA1ltyCl,lm(apppcable 1n all parties pstsd on above):The lnfboation provided in Pette 1.ll,and III orttrls form should be Coneldered confidential,prop ry. <br /> secret in accordance with 70 14,CCR,Section 17041 eLeeq,should any member or the public request disclosure of this Information;I request that CNJMB Contact me at the <br /> address and the telephone number above. <br /> ef�ctranlc R�porttng to CMINtB:Tri-C,Inc-has been auttwdzed by CIWMB to participate In the Waste and Used The Manlfeat EDT electronic roportinQ program.on behalf or the <br /> Etectroni listed on this corm.TA&Tire,Inc wlN elearonicaliy transmit to CIWMB all required iniormation from this mantfast form. <br /> customert roily that under penalty of penury under the taw%or the Slate of Califo la that the Information provided above Is true and collect•In es cod I am aware that falsification or Ihts <br /> innal yup a52 result <br /> ults per daynaper,revocation <br /> ev fatior ador danial of ministrative peen Ities�to Sshoo or violation Tire Hauler pier day es descrlbed In P3trafion pursuant to lubllo FieeResouou soCoda stccilon a2B62on 42960 d may result in civil <br /> M ?o /f'✓�s i l.se <br /> Driver's Flame(Print) <br /> Driver's Signature Date <br /> c�Dorto 1' <br /> rQ <br /> G <br />