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�+a—.��r.r_c��� 1.e.r•�f.�nrt i f\1—l. 1 11�L IYV. f.� .r.C/7 <br /> r. 'Tire Recycling <br /> 1558 Thys Court <br /> ,acramento, CA 95828 MUM4rh <br /> ft, 9%,388-2093 Fax: 916461-5412 <br /> 119 <br /> 1w7 <br /> �j�,Pj,�.► u�tM; 7RANNON TIRE <br /> �� �� LSON WAY <br /> STOCKTON, CA 95201 - STTON,CA 95201 <br /> v_ <br /> Phone;209-993-2828 JADIM C Contact:209-993-1358-?RED Phone:209-462-5398 Contact: ®m <br /> PE3CCHPagel / 1 <br /> ANGb 4S' <br /> TRAILER <br /> 1-pD.1005559 DC"1=06-01100 Ljsc=9C4&165 <br /> 22755 WASTE ®N <br /> 5/15/2006 Mon 1`8 LO <br /> llri ver Notts: $725.06 PM TRAU M-EXCHANGE <br /> k' <br /> �ilisste Til nest Form or EIe S�F n� )Data p�'r���oo�l(NVMB Form E®T) X71 <br /> TIRE PROGRAM ID: — <br /> MANIFEST#: M �._ ❑Fa is Tri-C Tire,Inc. a9 shown on the top of this fo <br /> TRAILER: ❑ Drop off (if applica !moi AL -Pick u <br /> TRUCK#:L7--STATE; LIC PLATE:#: G DEG #: —� <br /> DRIVER LICI=NSE#�--_----- <br /> (If applicable,;roan CIWMB Form 648)LOG#: L_-_,—————-- <br /> 4auter Exemptlon: ❑ Govemment. p griculture ❑ LEA;Exemption O Common Carrier <br /> Part 2:Load Information:Check one: Up ❑Delivery Pipplica4le,check one:El Import ❑Export Imp/F�cp Location: <br /> Load_Speclflcs' intended Use for Tlres: ❑Retread tD4kZccycla ❑Fuel O Disposal <br /> Tire Count Measurement O Whole Tire Count ❑Cubic Yards O Weight In Lbs ❑Weight In Tons <br /> Other Product counts 13y Type(If applicable) <br /> The Counts By Type Other Product A: Count Rate Total— <br /> passenger <br /> "atal _ <br /> Passenger: Count Rata Total Other Product B: Count Rate Total <br /> Trow. Count Rata Total <br /> Tractor. Count Rate Total Other Product C: Cougt Rate Total <br /> Other Product A: Count Rate Total <br /> Trailer. Count Rate Total <br /> Other: Count Rate= Total <br /> Sub-Total l: Count Rate Total Sub-Total 2: Count Rata Total <br /> Cash Amount Check Amount�—Check# <br /> Purchase Order# I ` <br /> 1 certify that u er penalty of perju4urn4det the laws of the State a;Calliomia that the Information provided above is tr e i come�� 6 6 <br /> © F A /`�Jp <br /> 5n.tp Date <br /> Facility presentatl e' Name(Print) Facility R presentati Signature <br /> Confldanttallty claim(applicable i all patties fated on above):The Information provided M Parte I,Ii,and Ill of this form sh be considered confidential,proprietary,andlor trade <br /> secret M ac:ordance with Tula 1a,CCR.Sectlon 17041 etseq,should arty number of the public request disclosure of this Information;I request that CIWMB Contact meat <br /> the <br /> address aid the teleptme number above. <br /> Inc.hes been authorized by CIWMP to partlClpata in the Waste and Used Tiro Manifest EDT electronic reporting Pwmm.On behalf of the <br /> ElQctrontc Rsparttng to CIVL'Fi1B:TrFC, <br /> customer listed on this roan,Td-r-Tim Inc.w111 eiecarontcally transrNt to CIWMB ell required Informoon from this manifest form. <br /> re that tatslflcaticn of this <br /> {ceaat under peraeltyof penury under the laws of the Stale of Californls that the Infawnatlon provided above Is true and correct.In additlwi.i Wm awa <br /> fify that <br /> Inrormat!on may rased In suspension.revocation,or denial of renewal of the�Waste The Ha er R*gistrvAon pursuant to Public Resources Code secilon 42660 end may fesuit in civil <br /> u e o r day, r violation or admirtis, u 000 rf� olaiion per day as described In Public Resources Code Section 42982. <br /> Driver's Name(Print) Drive Signature Data <br /> dynaaQr� <br /> e <br /> n <br />