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�..� ctecycling <br /> 3588 Thys Court <br /> iacramento; CA 96828 <br /> 3h: 916-388-2093 Fax: 816-381-5412 gin= <br /> BRANNOX-ALPINE YARD BRANNOS TIRE <br /> 07 <br /> 1624 EAST AVE. 3730 WILSON WAY <br /> STOCKTON, CA 95205 STOCTTON,CA 95201 <br /> Phone: Contact: Phono: Contact: WV <br /> PXXCfIANGE 451 Pagel / 1 <br /> TPID=1005559 Dtctl-0641093 taso�M9718 TRAILER slam <br /> 100=01M III's 1111 !n1* <br /> z335o W <br /> 1107202 6/7/2006 N <br /> Driver Notes: 5725.00 PER TRAILER AT ONE 45 TLR•EXCHANGE <br /> Waste Tire Manifest Form for Eltectrcinlc Data Transfer (EDT) <br /> TIRE PROGRAM ID: l O_7 r� SITE SUFFIX: �� of applicable,from CIWM13 Form 647) <br /> MANIFEST#: M - ' ❑Facility Is Tri-C Tire,Inc.as shown on the top of this fo <br /> TRAILER: Drop off cif a [e ❑ up# Jr <br /> TRUCK#: Qt2_-�STATE: LIC PLATEM 1e � ,..r pECAL4:,a_, G' -3 <br /> DRIVER LICENSE#_—__,_-_— (if applicable,from CIWMB Form 648)LOG#; L--_—_"__.— <br /> Hauler Exemption: O Government ❑ Agriculture EI LEA;Exemption C Common Carder <br /> Pali 2:toad Information:Check one: ck Up ❑Delivery �f-ap'pllcable,check one:O Import ❑Export Imp/Exp Location: <br /> Load SWIfics; Intended Use for Tiros: ❑Retread ecycle O Fuel ❑Disposal <br /> The Count Measurement:in Whole Tire Count D Cubic Yards 0 Weight In Lbs O Weight In Tons <br /> Tire Counts By Type Other Product Counts By Type(if applicable) <br /> Passenger- Count Rate Total Other product A: Count Rat® Total <br /> Truck: Count Rate Total Other Product B: Count Rate Total <br /> Tractor Count Rate l� Total Other Product C. Count Rete Total <br /> Trailer: Count Rate Total Other Product A: Count Rate Total <br /> Other. Count Rate Total <br /> Sub-Total l: Count Rate Total Sub-Total 2: Count Rate Total <br /> Purchase Order# Cash Amount _Chock Amount Check# <br /> I certify that under penalty of perjury u der the taws o{the State of Califomi that the'nformation rovided ova is true and correct <br /> Facility Representative's me(Print) Facility Rep Motive's Sig tura Date <br /> confdrtetttlaQty Ctatm(applicable to all parties kated on above):The Informitlon provided In Parts I,It,and III of th rm should be coneidereq confidential,propdeury,and/or trade <br /> secret In accordance with Title 14,CCR,Section 17041 etseq.should erny member of the public request dlaciosure of this information;I request chat CIWMB contact me at the <br /> address and the telephone number above. <br /> Elaetronle Reportiml to CIWMB;Trt-C,Inc,has been authorized by CIWMB to partielpate in the Waste and Used Tire Manifest EDT electronic raporlJng proorem.On behalf of the <br /> customer fisted on this form,Tri-C Tire,Inc,will etectrunkalty transmit to CIWMB all required intonnatton from this manifest form. <br /> 1 eertiry that under penalty of perjury under the laws of the State of Callfomla that the information provided above is true and correct.In addition,t am aware that faisircatfon of this <br /> Information may result in 6uspenslon,revocation,er do Mal of ranewai of the'Waste Tire Haulty Registration pursuant to Public Resources Code section 42960 and may result In civil <br /> pepaftigs u-1 �IlpO per <br /> day olatlono adminls pat ' s u 000 per tion per day as described to ubUe Resources Coda Section 42862. <br /> +� �`—z� 111 ^,/d <br /> Driver's Name(Print) Drivot' i9naturo Dale <br /> 'O"Drtro X <br /> bQ �� <br />