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10/01112005 19:44 2094776909 MARC'HEiTI BPOS PAGE 01 <br />Tri -c Tlr Recycling <br />8888 Thys Court <br />Sacramento, CA 95828 <br />Ph: 916-388-2093 <br />NICK MARCHETTI <br />7666 S ELDORADO <br />FRENCH CAMP, CA <br />Phone: 209-649.5281 Contact: NICK <br />,I pjDc l p05559 Decsl� Lisa° <br />Fax: 916-351-502 <br />Tue <br />NICK MARCHETTI <br />7666 S ELDWADO <br />FRENCH CAMP, CA <br />Phone: 209-649-5281 <br />PBOX DELIVERY <br />BI,K <br />Contact: NICK <br />Driver Nates: Stay witi) box when they load, bill at $1000 a box plus $7 -/hour for load time Thursday morning, call fire! <br />Waste Tire Manifest Form for Electronic Data Transfer (EDT) <br />TIRE PROGRAM ID: SITE SUFFIX: , _ (If applicable, from CIWMB Form 647) <br />MANIFEST # M j :T 1 +B Facility Is Trl Tire, Inc. as shown on the top o1 this form, <br />TRAILER Drop off (if p i1ceble)O Pick up # <br />TRUCK #: _ STATE _ LIC PLATE #. (=U- DECAL #: CL - Q — <br />DRIVER LICENSE # _ _ — _ _ (If applicable, from CIWMB Form 348) LOG #; L_ <br />Hauler Exemption: G Government Agriculture O LEA Exemption O Common Carrier <br />Part 2: Load Information: Check one,ffl ick Up 0 Dellvery if applicable, check one: 0 Import 0 Export Imp/Exp Location; <br />Load Specifics: Intended Use for Tires: 0 Retre�7 Recycle 0 Fuel 0 DispoSal <br />Tire Count Measurement. C1 Whole Tire Count T,Cubi` ccYY,ards 0 Weight in Lbs C Weight in Tons <br />17684 <br />,IMON! <br />i <br />Pagel / 1 <br />s <br />,EANUP ' <br />Tire Counts By Type - tither product Counts By Type (If applicable) <br />Passenger. Count Rate Total Other Product A: Count Rate Total <br />Truck. Count 7f� Rate_ Total Other Product B Count Rate Total <br />Tractor. Count Rates Total Other Product C Count Rate Taal <br />Trailer Count Rate Total Other Product A: Count Rate Total <br />Other Count Rate Total <br />Svb-Total t: Count Rate Total_ Sub-Tolal2: Count......_.— Rate Total <br />Purchase Order # Cash Amount Check Amount Check # <br />I certr'y that and nalty or perj under the I5w3 Of t re tVs of Coliforl that the ormation provided abev is !rue and correct, <br />Facility Representative's Name (Print) ~ Facility Representatives Signature Date <br />Confidentiality Claim (applicable to all parties listed on above): The Information provided in Parts 1. It, and III of this form should be considered confidential, proprietary, and/or trade <br />secret In accordance with Title 14, CCR, Section 17041 or seq. should any member of the public request disclosure of Ols informabon; I request that CIWMB contact me at the <br />address and the telephone number above. <br />eloctronle Reporting t0 CIWMD. Tri -C, Inc has been aut!iorited ty CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program, On behalf of the <br />cuslomer listed on this form, Tri -C Tire, Inc will aiectroncally transmit to CIWMB all required information from this manifest form. <br />I certify that under penalty of perjury under the laws of the Stale of California that the information provided above is true and correct. In addition, I em aware that falsification of this <br />information may result in suspension, revocation, or denial of renewal of the ate Tire Hauler Req stration pursuant to Il Resources Code section 42980 antl may rill in r_ivil <br />pantell to 526,000 r day, per vlWatlOn Or adminlstratlVe +tl p S6,tl00er vl tion per bey as described in Pu Resources Code Section 42982. <br />Driver's Name (Print) o ver'e tgrtatu Date <br />wc Dare r, <br />,i <br />