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Rom:LAKIN'FIRE WEST,11Fex!(M)MBD-3733 To:+13092317849ao
<br /> Fel•' +'I'Oti-_178441 Pnrye 3 of 3 M/2I/:016 9:34 Alvl
<br /> 7tC, r1RE
<br /> 1161'700--1
<br /> Pickup Receipt Pickup Date. 09/20/2016
<br /> EDT Maniftsst: 110171)0731
<br /> EDT Trip Log: 585579
<br /> Store No: 036J'6
<br /> Generator Hauler and End Use Facility
<br /> FIRESTONE TRACY Lakin Tira W83L
<br /> 940 VENTRAL AVE 15305 Spring AVG
<br /> TPA(:y , CA ci53 76 Satita ire Spring,-;, CA :3111170
<br /> PHONE: 209-221-7154 P110NE: 800-498-2752
<br /> TPID: 1694054-01 TPID: 1000G59-01
<br /> Truce:: 42.3468
<br /> 'frailer: 53723
<br /> LiCGnse Number: 9F34029
<br /> Registration: 1E-0.?345
<br /> $tat9: CA
<br /> item (Whole Twres) Qtv
<br /> 'rirge P5,cl:ed a .1
<br /> RV Tires: 2
<br /> DRIVER: SOTELO, JORGE N
<br /> S�7.dnrxturae of Hauler / Generator
<br /> " i C.at;Py that undae p:urlcy „t Porjury m,J.r the Tawe of tlr. at,.are
<br /> of Cali focnia tnat tno 11120did"J,:•n provided above it$ truo and Cuc rem,
<br /> ,,,P r. 3' / 'a�r I`. � ,1' t j•a"�l,:q � In add;%;—, I on award thuc t,.r an iniomr cion —Y•'';.�,�I�.; r F,,�r. "�" !),.�•: r-,`, 1 niiivation of eh'
<br /> a { V i'�"1N Y Y 16 DCII 1 ronin[ In rurponaion, rovuuuai..n. or doniai of ..nv,4i of th. mrrer
<br /> °�:+ t'i 't'�:' �r 1• •r Re9iorcation put9rbyn
<br /> y i� Tire HrJl
<br /> 1 tee PubllC rlrrm¢,
<br /> (r;.(@h a Cbdo sac cion
<br /> 4. r "��9• jW{t' �,� ? 1Y'' rJ25d0 ind as result in Civl >
<br /> vial.tlon oryadminiocruriv. 1"naitioo up cu S$$,Upa per da
<br /> y, I+tir.
<br /> ennttiee u' cu 65,nUU
<br /> A ,t'I��' �'�•�` W�' p `%" 1 � P Y bee vtolution Per
<br /> Jay rr deoc[ibod in vuBlie Ree•vncr_o coda r.cia cn 91462. "
<br /> It. iai'.i�'fdS41a U°•�'il{,{,;;r' b,f
<br /> i'2 � �i� I, ,1 n��f�?lE;lf� •'�1'„� GENERATOR: KFVTN VIN17ENT
<br /> "I CaCtify that under panaltY„i pju[Y undae t . lawn of tno UCa L'u
<br /> I�,';n»:•msih�i.�'�(,:S�I;.,a�`„' d n?'a 1 loll Cf�,s11( 1,4 of arli,£r,rnia that ceo tnt-c,ari:,,-,n Provided ab„— t” true and
<br /> oorl.at.11
<br /> Confidentiality Claim. The information pr.civided or, 'Chi:; Ftarnl shoulr_1 be
<br /> Dw�ea? r.onsiderGd confidential, proprietary, and/�:�r trade sacral. 1'n ac•corClaUre. with
<br /> Titlo 14, VCR, Section 17041 et;.seq, should any membor of the public request
<br /> w Ppb ;; disclosure rel Lhis informar-iw,, I request that Ca1.Necy'::La curlLact. Me at CtYly
<br /> Gw,
<br /> address and telephone number 2buve-
<br /> Electronic Reporting to calReayoie: Lakin Tire West hats been authorized by
<br /> CaLlRer;ycle to par'tiCipaL-e in the Waste and Used Tire M-i111ifQ5t EDT electronic
<br /> reporting program. Un behalf o1 Lha cuotomer listed on this form, Lakin Tire.
<br /> West will G1eCtro1-1i,=a:1..1y transmit to CalRecycle all roquired information irom
<br /> Lhis manifest. CalReCycle has approved the Lakin Tire w,:;st EDT form. I.-Or use
<br /> wiLhin the Waste Tire Mani resit System 2DT progr'a,u_
<br /> Questions? Please contact your Customer Service Representative at 800- 188-2752 or email
<br /> customcrserviccrL3lakiutire.t:':�m.
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