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--- JUL..L`i.CUvjc:) J.U•'-F'i"Ii II\1 lr\,— <br /> "v• <br /> I <br /> �r1,e Mrs. g®tycling <br /> MIT, <br /> 1588 Thys Court <br /> lacramento, CA 95828 � ( <br /> 'h: 916r388-2093 Fax: 916-381-5412 <br /> BRANNON TIRE <br /> MANNON-ALPINE'YARD 3730 W7 <br /> ILSON WAY <br /> 1624 FAST AVE. STOCKTON, CA 95201 <br /> STOCKTON, CA 95205 <br /> ----j Phone: Contact: ®® <br /> Phone: Contact: Pagel /I <br /> pEXCHANGE 451 <br /> TRAILER <br /> TPM-1005559 D=1=06-01100 1ascx9c4E165 110 <br /> 2300 112 <br /> 1107202 5/23/2006 Tae. D <br /> Driver Notes: A <br /> ox-1 <br /> e)-12 F <br /> V <br /> Waste Titre Manifest Form for Electronic <br /> - SITE SUFFIX: ��eta pTralnsfOre.from (EDT)WMB Form 647) <br /> TIRE PROGRAM i • j 2 a <br /> MANIFEST M. 3 © � [3 lity is Trl-C Tire,inc.as shown on the top of this form. <br /> /7/R (�f appljcable)❑ Pickup# <br /> TRAILER: Drop off DE #: O -�-�—� <br /> TRUCK*�� —�STATF:�,— LIC PLATE#:1 .1 <br /> DRIVER LICENSE#_�__— (1 applicable,from CIWMi3 Form 648)LOG#:l--__---- -- <br /> Hauler Exemption: ❑ Government p Agricultu LF-A Exemption ❑ Common Carrier <br /> Part 2:load Information:Check one:0 Pickup li a Recyclelf p1O Fuel ❑p spo alcheck one:p Import <br /> ❑Export ImplExp Location, <br /> Load Specifics: Intended Use for Tires: Cl Retread <br /> Tire Count Measurements O Whole Tire Count ❑Cubic Yards ❑Weight in Lbs ❑Weight in Tons applicable) <br /> Other Product counts Uy Type(if pP ) <br /> Tiro Counts By Type Other Product A: Count __ Rate Total <br /> passenger. Count_ � Rate Total Other Product 13; Count RateTotal <br /> Track: Couni Rate Total other P(oduct C: Count Rate Total <br /> Tractor: Count Rate Total Other Product A: Count Kate Total <br /> Trailer Count Rate Total <br /> Other. Count Raje= Total Sub-Total 2: Count Rate Total <br /> Sub-Total 1; Count Rate Total Check#-- <br /> Cash Amount Check Amount — <br /> Purchase,Order# � d- <br /> 1 certify that under penalty of pedu under the laws of the State of California that the information prowdvd above is ndcorrect. <br /> r <br /> U I <br /> 9entative' ame(P nt) Facility osentative' g <br /> nature Data <br /> Facility Rep <br /> confidentiality Ctalm(811p ]cable to pattlea listed on above):The Information provided in Ports I,11,and tit or 1015 form¢hoard considered conFidentlal,proprietary,eat it trade <br /> secret to accordance with Title 14.CCR,Sack on 17041 et eeq,snouid any member of the public request disclosure of this info 0M.I request that C1WMa confect ma at the <br /> address and the telephone number above. ram.On behalf of the <br /> cIPAtu <br /> Electron listed <br /> �9 IWM,.Tire, aware wh2d;been <br /> authorized catty transmit I MS t oilldrequlred lnIn ttorm�otlon from this alte arid amanifeat fiortn,ROT electronic reporting Pro9 <br /> customer I <br /> t certify that under penalty of per}ury undo the taws of the State of Caifforr<}a that the Inromtutlon provided above Is true and correct,In addition,I am aware tnel falslfiCdtlon Of this <br /> infonttatkm may result in 6yspension,revocation,ordenlal of rani of the Was QaTlre Hauler R�golee dlmyasdesc ibed InuPublic ll eResov ce&Code Section 42862, may ro9ult In civil <br /> penal ee s,oaa per da Violation or administrative p 1. <br /> 6761s-e s Name(Print) <br /> Driver's Signature <br /> U <br />