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<br /> P:LC tup Receipt Pickup Date: 02/23/2016
<br /> ,-WT Manifest: 19,01570662
<br /> VDT TrIp Log: 456681
<br /> stow 1Qo: 03GJ6
<br /> FIRESTONE TRACY Lakin Tire West94 0 CENTRAL AVE 15305 Spring Ave
<br /> TRACY, CA 95376 Santa Fn sin ,A ,90670
<br /> PHONE: 209/221-71G!1 p gs C
<br /> TP,T,D: 19948$4-01 PHONE: 900-•488-2752
<br /> TPr.D: 1000659-01
<br /> Txuck: 423468
<br /> Trailer.: 2797a2
<br /> LtOO-nze NumbOr: 9x34829
<br /> Reglstration: 16-02345
<br /> state: CA
<br /> item (�!ia0,e Tiz��a) r Q, y
<br /> Tires T60—io YTp:
<br /> . ,w 16B
<br /> S�ematq r �rato� DRIVER: SOTELO, JORm y
<br /> I oart].ry ':he+t undos p.nnny of norlury under r.pe 1,a14e of t114 .St&L f
<br /> I� � r�.4.��illp,,�l,441 � j3� 1iEl;I �I qty.. of Crrl.ifornir chat L'Mq 7,nlormation psrnrJ,dn;i abrn-c 1,:o r„sus nn+3 carzogC.
<br /> em nwota rhnt .falcif4cemLon e( r,
<br /> {{ �, a ,• i ':�i;;1” a pic information may
<br /> in cua anal,all revocation, or den,ica of rr-ngwa:I. fif The Y -co
<br /> a.
<br /> L, P "Irij J' rs+ �;•n iii';:" Tire Raulwr nn9,1411f,ation puzuunnt Eo Public A,aurnn Catic section
<br /> SI rybr' 12060 and MAY .r,47141 in Civil ,n
<br /> � n1'rSc¢ up to Ea,.ry,gg1•
<br /> 0 yar day. p4
<br /> !., �rl p+; v1.01anion or. Atmifd.et¢ati.ve p t.a ss,penAltion u
<br /> °,I' �, 1• 'I I I l r, i'i„ 000 pox vi.oa.nt,lnn nnr,
<br /> n-i'll ''? III' ,r M +..JI + I ��ejl` '`AIJ�`'I' 4py �rt dAaeribed in Pu11
<br /> Cr�An beetion 400
<br /> �I rd � ill ''ia I GENERA,TdR: JAMES GLAZE
<br /> '' Vii;. . -.tiii it I}I ;► i1,1 G,,,.r':I,,.
<br /> .'h "I certify rhat ander panalt of perjury
<br /> �..tii1,;i:'L fc:,dl ?i,rrlly i�lf•�r��:!�!'" of Califarn�t,n Y R-rJury ugdmL Lho ].Aac of tha gtntn
<br /> Ch!+C til is�grm�rtlon Provi.dod Aho" i� trua AtIll
<br /> ��eiAals� Cc2Xftdent i4Q.;.ty Claim: The itlfo,T ation provided on this form ghmld be
<br /> o. cannidered d:onfidenti.a7,, propria,I M,ry, and./c,.r trado secret. I,t,,i ac:cotdstnce With
<br /> Title 14, CCR, sect ton 17041 rt.seq, sh014cd any member of the puhl �C request
<br /> o disul.osure of Lhi.s in£Oxmation, I request that CmlRecycln Contact Zile at thr.9
<br /> addrmas and ' tlephone number albovt.
<br /> Electro=c RePCM'ta.ng to CtJJteop'c1At Lakin Tire West has been guthori:�pd by
<br /> aallRecycle to part I.ci.pate in the We!ate and Umod Tire Manifest QAC ele,cttion,ic
<br /> rfpq,rtxng pxoyram. On, behal,l' of the cuotomer li,gted on T13i,q foxzn, Lakj.dz Tiro
<br /> West Will ele+c.9:ronicall,y tran.srdt to Cal.ReryCle all required infO=ation from
<br /> 'this mani..fest. CRIReaycle has approved tte Lakin Tike Wept EbT f�x7:n for g,ae
<br /> within the Waste Ti.re Mani.fes�_ System EDT program.
<br /> Questions? Please co»ta, r CURtbmecustomeXsezviae@lakin'ki,re.c4ft, r sOrvi,ce RMPzesentative at 800-4eC-2752 ore qi,1
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