COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

-j UL.G4.Luuo 1 VJ-4JHI'I I Ki—l- 11Kt NO,73 P.7/9 the Recycling 1588 Thys Court iacramento, CA' 95828 ft 916-3882093 Fax: 916-381-5412 k BR.ANNON-ALPINE YARD BRAIQNON TIRE 1624 EAST AVE. 3730 WILSON WAY STOCKTON, CA 95205 STOCKTON,CA 95201 hone: Contact: Phone: Contact: ? Pagel / 1 r?ID-1005559 Decal-06-01100 Lhcr9C48165 fay •to rµ 1/� 1107202 7/5/2006 1 Wed ' 29988 N Driver Notes: $725,00 PCR TRjkjLFR+$35.00 FUEL SURCHARGE Q ONE 45 TLR-EXCHANGE dO Waste Tire Manifest Form for Electronic Data Transfer (EDT) --F � TIRE PROGRAM 1D: ?� ,Q 7� SITE SUFFIX:� (If app licable,from CIWMI3 Form 647) -- MANIFEST#: M [.`� ❑Facility is Tri-C Tire, In as shown on the top of this form. TRAILER: �Drop off � S (if app able Pick,lp# - � TRUCK#:_— t� TAT : Ll PLATE# � ��( DECAL#: DRIVER LICENS0,4— f applicable,from CIWMB Form 648)LOG#:lL-, _,__.__�— Hauler Exemption: ❑ Govemment ❑ Agriculture O LEAExemptlon ❑ Common Carrier Delivery If applicable,check one:El import 1:Export ImpfF-rcp Location: Part 2:load Information:Check one:Q;Pick t1p ry PA Load Spaciflcs: Intended use for Tires: ❑Retread 'Recycle El Fuel O Disposal Tire Count Measurement,13 Whole Tire Count ❑Cubic Yards ❑Weight In Lbs ❑Weight In Tons Tire counts By Type Other Product Counts By Type(if applicable) Passenger. Count Rate Total Other Product A: Count Rate Total Truck: Count Rate Total Other Product S: Count Rate Total Tractor: Count Rate Total Other Product C: Count Rate Total Trailer: Count Rate Total Other Product A: Count Rato Total Other: Count Rate Total Count Rate Total Sub-Total l: Count Rate Total Sub-Total 2-, Purchase Order# Cash Amount Check Amount Check#_ I certify that undor enalty of pot, underth tawsrpf the State of California that t Information provided above`is k and correct. cD Facility Representative's Nam rint) Fad1itY,1,'.;;;sant2tiv Ignature Date uIri he is form secret.•n accordance Wth Title(applicable 14,CCR.Section listed7041 eLesq,anThe uldf any memation ber of the p blicare.11,and III of que t disclosure of Into information;I equ sered t that CIWMB contact Rte at thewade address and the telephone number above. pactronle Reporting to CIWMB:Tri-C,Inc.has been authorized by CIWNI6;p Particlpate In the Waste and Uoed Tire Manifest EDT electronic reporting program•on behalf of the xstomerlistad an this Form,Tri-C Tire,Inc.will electronically transmit to CIWMB all required Information from thio manifest form. certify that under penalty 0 perjury under the laws of the State of California that the information provided above la true and carr Ct in addltlon,I aM awarethat falslfieat On of thls nformatlon may result In sus Ion,revocation,ordanlal of renew f the Waste Tire auler Registration pursuant to Public eeou s Code section 42®6o and may result In civil lenalties up oa�ti26,000 per ay per I tion or adminlstn3tiva a up to 0o r vl laden per day as describ dI P Il R ureas Code Section 42962. 06 Drivers Name 'int / Drivers ignat re ate o<,C DWI" W.