COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Tri- c-Tire Recycling 8588 Thyg Court Sacramento, CA 95828 Ph: 916-388-2093 Fax: 916-381-3412 $f� .A&J AUTO PROS A&J AUTO PROS 8423 S.ELDORADO ST. 8423 S-ELDORADO ST. FRENCIJ CAMP, CA 95231 FRENCH CAMP,CA 95231 Phone: 209-983-8774 Contact:JOE Phone:209-983-8774 Contact:JOE � PICKUI('TICKET Pagel /1 TPID=1005559 Decal- Usc� MR n # 19819 CCJI35 1/20/2006 Tue AC 2DE � Driver Note7: 51.05 PER TTU IP,F,S.PER JOE z Waste Tire Manifest Form for Electronic Data Transfer (Ebb) TIRE PROGRAM ID: L SITE SUFFIX:C�l`�—(If applicable,from CIWMB Form 647) MANIFEST 1r=' M / -/ � ❑Facility is Tri-C Tire. Inc.as shown on the top of this form. TRAILER: ❑ Dro off Otto plica e) ick up# TRUCK#:_ _STATE: LIC PLATT# Gy � L DECAL#: OS- Hauler LICENSE# _ (If applicable,from CIWMB Form 648)LOG#: L_ _ Hauler Exemption: ❑ Gov—em ment L Agriculture ❑ LEA Exemption ❑ Common Carrier Part 2:Load Information:Check one:Q'Ack Up O Delivery If applicable, check one:D Import ❑Export Imp/Exp Location: Load Specifics: Intended Uae for Tlrks: ❑Retread ❑Recycle ❑fuel U Disposal Tire Count Meaburement: ❑Whole Tire Count D Cubic Yards f,J Weight in Lbs q Weight in Tons Tire Counts By Type Other Product Counts By Type(if applicable) Passenger Count Ratev 5 Total �=��ss Other Product A: Count fate Total Truck: Count Rete Total Other Product B: Count Rate Total Tractor: Count Rate Total Other Product C: Count Rate Total Trailer; Count Rate Total Other Product A: Count Rate Total Other: Count Rate Total Sub-Total f: Count Rate Total Sub-Total 2: Count Rate Total Purchase Order# Cash AmountCheck Amount Check# I certify that under pe of perjury under the laws of the State of California that the information provided above is true nd rrect. If– racility Representative's Name(Print) Facility Representative's Signature Date Confidentiality Claim(applicable to all parties listed on at)ove):The information provided in Parts I,It.and III of this form should be considered Confidential,proprietary.andlor trade secret.In accordance witn TltLe 14,CCR,Section 17047 et.seq,shouid any member of the public request disdosure of this information.I request that CIWMB Contact me at the address and the lel9pnone number above. Eioctronic Reporting to CIWMB:Trt-C,Inc.baa been authorized by CIWMB to partlClpate in the Waste and Used Tire Manifest EDT elCUronic reporting program.On behalf or the customer listed on this form.Tri-C Tire,Inc.will eiec"mically transmit to CIWMB aft required information from this manifest form. I certify that under penalty of perjury under the laws of the Slate Of ra that the information provided abovo i*true and oonea In addition.I am swsre rnat f3lSification of this infOrmation may result in suspension,revocation,or denial of renewei of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil nehallles up to$25.00D per day.per violation or administrative pens) es 55.000 psr vicistion per day as described In Public Resources Code Section 42962. Driver's Name(Print) Driver's Signature Date �q a a A +;.. vl'.