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FROM :HANMER 3583 FA'X r10. :9511252 nec. 16 2004 01:26PN P2 <br /> i <br /> Waste Tire Manifest Form for Electronic Data Transfer (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:westservlce@lakintire.com (562) 602-7584 Fax <br /> �NHauler ❑ Generator.,... End Use Facility <br /> DATE: <br /> EDT Trip Log#: 1000659 __.__ / L -7 r. EDT Manifest#: 1000659- ;� )) 7 <br /> TGfD RIiN {✓ <br /> Mauler Information .,,.� —. --. Facililty Information: <br /> Name Name: �rJ <br /> AddlEss; (� Addresss. /� r <br /> City,State Zip: City,State Zip:`�•';� �� r /-/, �' <br /> .... <br /> Phone: Rhone: .,. ry'�2 r�> <br /> Tire Pro ram ID: r 2 P !. 2 G �� 0'>' <br /> IM Unregistered Hauler 4:0lt7PiCkLjp [J Delivery ❑Import ❑Export <br /> Hauler Exemption: ❑ Qovemmonr ❑Aryiurdturu aEA Caumpt ❑Common Carrier/Berk Haul Location: <br /> it Applirs0ler —< — --- / <br /> CIWMB-646 Trip Log A,L CIWMB-6,47 Manifest#:M . = �� I <br /> LoadingOrder: _ 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 ITotal ITotal <br /> Tire Count Measurement <br /> R Whole Tire Co�t: - i <br /> ❑Cubic Yard ! Trailer Number(a): 4:�5/;? <br /> Weight in L4. °r License Plate Number: C- r 2e,;• <br /> Weight in Toni State: r <br /> eq- <br /> Infena"UEe for Tires: Reeread Recycle Lj Fuel Lj CitsposAl Decal Nunliber: <br /> I Wry ther OnOer pennity of Tari.ryund-rho rows of Ow..Slaw of C:Aikrmia rtwl 1ho mformarion f-w,dnd nhnva is Inn And pnrreft.In adcilllon,I am aware wal ralelncenOn 0f <br /> [hie Inlormanon may maul)In nn:.nnnrinn•rnvwation,or Unrlial bf renawal of 0m Waele T�rE 11-1-Rugisvaau—pnsuanl Ie Publ{n Aomoun:ac Coln f;—t an d2`.x5()and mny <br /> r—AT In nivil ponnlvo.:up io$26,000 Per day par vi011lf on or 4a Minselralive 0e119Ll149 up Iu$5.000 our vwlariuri p*r Uay yc dosuribeii in Prlplin Ro wmvx C. &Sngtion 22!M2. <br /> _.:.. <br /> Driver!Hauler: - Facility Representative <br /> Si nature: .-- Signature: <br /> 9 <br /> Printed Name: '�J ,. p - f Printed Name: <br /> Date:. <br /> i <br /> ConfklertBalltyClalrn;Tho Informatlat provided on this form.ehouId be coneldorad conl'idnnri:o.propriemrery,nndrnr Inlrtn;anmr. In ar•.r,.nrdance with <br /> Title 14410R•Section 17041 etseq,should any member tl17►le plAblic request dleclosure of this lnformnuon,I req,,jas1 Jh31(SIWbAH 0Ur1fAC1,Mb Al p10 ,. <br /> gddrase.and tekephone number ftbove- <br /> EleogiWhfER6perting to ClWMU;Lakin The We81,Ino.has b9en.A 4hodtf5dby CIWMS IU part6pate ui we Wnle and UdndTIK Mwiftna LOT ale trunic repoiring paigrbrn. <br /> On uehalrAr:me.oAtO111si Jmed Oa T.mis tow.Lakin Tire Weel.hie.Wilt ekJClrerQ Wly traa.net tP CIWMB nil:faquimd.in1lonrA an from lhi>t ffumlfnm.("Ump.hnA ApprNod tho <br /> Lakin Tire Weal EDT forts rOr U6u.Within the WaME Tire Merxf6til.9ytilaill rcrn prfmminn, <br /> t'If IC-rr%k AI L--ES/'IA1 r)%/ <br />