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i <br /> Waste Ti._ Manifest Form for Electronic Date. ransfer (EDT) <br /> A LAKIN TIRE WEST, INC. <br /> 15305 Spring Avenue (562) 802-2752 <br /> Santa Fe Springs, CA 90670 (800) 488-2752 <br /> E-Mail:west..,s,,LLervice@lakintire.com (562) 802-7584 Fax <br /> �.Nauler ❑ GeneratOt . End Use Facility <br /> DATE:���_ <br /> EDT Trip Log #: 1000659 -__ __ / r7 /�� EDT Manifest#: 1000659- <br /> TPID RUN-# / 5 2c�, („7 TPID Receipt# <br /> Hauler Information: Facililty Information: <br /> jNamefso51 ill 1�/a7L ✓,' � , Name: <br /> Address: ' ' Addres';ss: <br /> City, State Zip: City, State Zip: <br /> Phone: Phone: <br /> Tire Pro ram ID: l ,~•__�� <br /> ❑ Unregistered Hauler :jPickup❑Delivery LJ Import❑ Export <br /> Hauler Exemption: ❑ Government ❑ Argiculture ❑LEA Exempt❑ Common Canter/Back Haul Location: <br /> If Applicable: <br /> CIWMB-648 Trip Lo #:L_ — ——_ CIWMB-647 Manifest#: M <br /> Loading Order: Count Tires Count Other <br /> Tires Delivered / Returned ,' Tires 12" - 18" Wheels / Rims <br /> RV Tires 18.5" - 19.5" Alternator Cores <br /> Purchase Order# Truck Tires 20" - 24.5" Starter Cores <br /> Farm / Industrial Tires Miscellaneous <br /> Cash Amount Adjustment Tires Aluminum Wheels <br /> Recalls <br /> Check Amount XOM <br /> DEMO <br /> Check Number <br /> }' [Total Total <br /> Tire Count Measurvrnant <br /> :l�Whole TirePo <br /> unt <br /> > ❑ Cubic Yar ss Trailer Number(s): <br /> ❑ Weight iny,LBS _' License Plate Number: <br /> ElWeight in -rtes.-. --'" State: �t�1� ��� <br /> Intended Use for Tires: Retread 'Recycle Fuel': Disposal Decal Number: <br /> I certify that under penalty of perjury under the laws of the State of Carrfomia that the information provkJA@bove is We and correct.In addition,I am aware that falsification of <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in PutbI Resources Code Section 42962. <br /> Driver/ Hauler: Facility Representative - <br /> Signature: —.�. - Signature: <br /> Printed Name- <br /> - ! ten ' —>----Printed Name:---- �° <br /> �_ <br /> Date:--r= --- ----- --- Date:_— IT <br /> / 1 <br /> -- ----� ---- f <br /> ` Confidentiality Claim:The information provided on this form should be considered confidential,proprietary,and/or trade secret. In accordance with <br /> Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information, I request that CIWMB contact me at the <br /> address and telephone number above. <br /> Electronic Reporting to CIWMB:Lakin Tire West,Inc.has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program. <br /> On behalf of the customer listed on this form,Lakin Tire West,Inc.will electronically transmit to CIWMB all required information from this manifest.CIWMB has approved the <br /> Lakin Tire West EDT form for use within the Waste Tire Manifest System EDT program <br /> �c DatQr <br /> do ,ptl <br /> A � <br />