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10/03/2005 11:59 209948'"-1 GEIGERCOONKEENLL- PAGE 03 <br />10/01/2005 19: 44 2094, 09 MARCHETTI BROS P4GE 01 <br />ir" Tire Recycling <br />r 111i�1 <br />8588 Thys Court' <br />3 ornrrwnto, CA 85828 <br />Ph,- gig -398-3093 Fax: 616.381.5442 <br />rr; NICK MARCHETTI <br />NICK MARCHET I 7666 S BLDOAADO <br />7666 S ELDORADO FR)J'NCH CAMP, CA <br />FUNC14 CAMP, CA <br />Phone: 209-649-5281 Contact; NICK <br />phone: 209-649-5281 Contact NICK Paget / <br />PBOX DBIrIYKRY <br />TMD -1005559 t}Ccet- LIK- <br />9/M005 Tut n'✓^ <br />Driver iYe(es, Slay with box wtrtrt they load, hitt at $1000 a box plus $75/ho,:r for coed time ThursdAy murIlling, call fust! <br />6 <br />Waste Tiro Manihst Form for Electronic Ditty Trrsnsfow (EDT) <br />TIRE PRQGRAM 10;, _ �.r SITE SUFFIX' _ ^ (if 80011404110, Nom Q%W0 Form 647) <br />MANIFCST #'M L j_,' �L ■plihr Is Tri C rine, trtc. as anown on ins top of tnia form, <br />TRAILER, Orop off (rt lira )0 Pick up #1 - Q <br />TRUCK IE; , _STATE: _ LIC PLATE is tf as l CamM1NMb Form �1: L <br />DRIVER LICENSE i�—�---- ( PP �--"--- ----- <br />Heulor Exemption' ❑ Go efnmgmt ^S rZvlturs p LLA E"mption o Common Carrier <br />Pert 2: Load Information' Check ons' ick Up 0 DNI ry If ORAC4 ble, ohecl( ane; 0 Import ❑ ExW Imp(E,xp Loceion; <br />toad Specifics: In>:rtded Use for Tires: O Retro RegteA O Fust O DioPosal <br />Tine Count �Meavunmrrt CJ Whole Tire Count Ctt��,Cublc YErds p Wool in Lbs C Weight in Tore <br />Tire Counts By TiPe Mor Product Counts By Type (M appftcable) <br />Passenger Count Rate Total ether Prod»d AL' Count AAIB T=I <br />Truck Count Date`_,,,^, Total Other Produet 4 Count Moto Total <br />Tractor. Covent Rate Total Other Procfuot CCount Rete Total <br />Trailer Court Rate Total Otffa Product A: Count Rate Told <br />other: Count Rate total <br />Sub -Total t; Count Rats Total Sub-Tolal 2: Count Rata Total <br />Purchase Order 8 Cash Amount Check Amount Check Ik <br />I certify that uri <br />any a per- under !hep Of total of COINOrnls that the ormalion provided abo is true and Correct. <br />A1C `�j i-7 e i 4—r- <br />Facility Represeritiwtiva's Name (Print) - Factfity Repress , ive'a Slon*iro Date <br />Conntlorruallty clelm (applicable to n!l Pertlaas tistad a, above): tris wwrrtstlon provided in Farts i. Il, and til or thistonin should De calaldaeo CDnndetrtlal, proprietary, anwof trade <br />660MI:. In 0cwtdance with 7111614, CCR, Section 1'7041 et.eeq, uroulo toy member oft publk request d}Pciosu a or tnis Wormettl I request that rtWMe contact meat the <br />aodress am me telsPnone wrier lean, <br />EISIMMIC 111WMAP to 4;0"1 TF -0, Ino. hes Dean aulhorited ty CtWMe to pMpats In the Waste"Wed Tire NwIlost EDT eieatrwfq reporting program, Qn behalf of the <br />ous"'m Ifaled on this form, Trp; Tire, Inc, will sladranp0y transmit to Cwhe ell requited inteamatioh from this manliest form. <br />I cod* that snider penalty, at perjury under Tile laws of The SINS of Calitomie that the wtformaticn proviond above is true and correct. In eddif;on, I am awere that I31e1fim"On of this <br />irrrom atter may reautt in wapeneim woo"fion. or dorial of rerwwal of the VVaabi Tire Rmler Replstr*00 Dur)uard to Public Resources Code section 4MD and may result in Civil <br />p yp W 11125.94150114f pay, par violation or admolxranve SO-00SPer per day as datem d in Pui wzumee Code SeMoh 42902. <br />--he/ it � tom. � �(f f rti-5 <br />Driver's hams (PrMt) +7r'a At Date <br />