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oug Thys Court <br /> aCramento, CA 95828 <br /> 'h: 916.388.2093 Fax: 916-391-5412 <br /> BRANNON TME <br /> BRANNON-ALPME YARD 3730 WILSON WAY <br /> 1624 EAST AVE. McKTON,CA 95201 <br /> STOCKTON, CA 95205 7 <br /> Phone: Contact: <br /> Phone: Contact: Pagel /1 <br /> PYCK UP 45'')i*RA1T.�ER <br /> 1® <br /> 'tyyD-1405559 boost 06-01093 Lisc-IP09718 <br /> �M <br /> 7�1-107202 6/6/Z006 "N6 <br /> Tg BOBC 23330 iN <br /> Driyer Not:ca, PICK UP 45 TRAILER <br /> d -4 gi <br /> � <br /> Waste Tire manifest Form far Electraillc Data <br /> Transfer (EDT)m CIWMB Form sal) <br /> TIRE PROGRAM ID: =� SITE Sl1FF as s <br /> MANIFEST#; M 1 ❑Facility is Trl-C Tiro,inc.as shown on the top of this form. <br /> TRAILER: Q prop off (if pplrca le P})'ck u <br /> STATE: LIC PLATE#: �. Y.Zl� DECAL#: - �-Q <br /> TRUCK#:L r ( applicdblar from ClWlI Form 648)LOG ---- <br /> pRNERLICE E#�._�— — — <br /> Hauler Exemption: ❑ Government Agriculture l7 LFJ1 Exemption D common Carder Location: <br /> Part 2:Load Information:Check one: rok Up O Delivery If applicable,1uel 0 D sposai❑Import D Export Impli=xp <br /> Load Spaclfics: Intantied use for Tires: ❑Retread -Ftt> <br /> Tire Count Measurement:Cl Whole T ifs Count O Cubic Yards ❑Weight In Lbs ❑Weight in Toes if applicable) <br /> Tire Counts By type Other Product Counts Sy Typ ( pp ) <br /> Other Product A: Count Rate Total_ <br /> passanger. Count_ Rate Total Other Product 6: Count _ Rate Total <br /> Truck: count Rate Total other Product C: Count Rate Total <br /> Tractor. Count Rata Total Other Product A: Count Rate Total_ <br /> Trailer: Count Rate_ Total <br /> Other. Rate Total <br /> Sub-Total 2: Count Rate Total <br /> Sub-Total 1: Count Rate _ Total Check Amount Check# <br /> Purchase Order'# Cash Amount �— <br /> I certify that under penalty of perjury unfir the laws of the State of Calffornla t t the rotor etlon provided above is true and corracl.'6�^ 66 <br /> n tJj Date <br /> �Fa <br /> Cf5 v Facillry presen e's SignatureRepse1101, <br /> nlative's a(Print) uld be of Contldar> Chlltn(6ppilcablstc et1 parties lleted on above):The Inforrn3tlon provo4thain p publicrequest 11,an dlIII ethic ureof this Infomratioonnngrequest that Cidered nWM6too itad me satholor lro o <br /> secrat.in accordance with Title 14,CCR,Section 17041 et.seq,should any mem <br /> address and the telephone rwmtier above. <br /> Electrorttc ReporUAg ooct Td8:Tina s aei�or,icainorized ly t to ciwmBpoill retglultred Information from tie manifest form.in the Weete and Used Tire manifest EAT electronic report ng program.On behalf o e <br /> customer listed on this <br /> stratlon pursuant to Public Resources Code secllon 42980 and may rosutt In civil <br /> 1 certl(y,that under penalty of pedpry under the laws or the State of Cailiomla that the Information provided above la true and cortret•In addition,t am aware that faislbcation o �s <br /> 0 t Hauler par day as described in Public Resources Code 5ection 42882. <br /> Information may result in suspension,revocation,or denial o!renewal of Waste Tire rv1d <br /> p s up 10 x+,000 r day, erviolation or admitllstre pe It per P .�� <br /> � "�nf__ <br /> • Drivers gnat o <br /> Driver's Name forint) <br /> '06➢ara� <br /> d <br /> k <br /> I <br /> l <br />