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—'� JUL.C4.GO16b- 11J-45H1'I I H1—U 11HE N0.73 P.8i9 .re Recycling 3588 Thys Court Sacramento, CA 95828 Ph: 916-388-2093 Fax: 916-381-5412 BjZ4NNON-ALPINE YARD HRANNON TITLE 1624 EAST AVE, 3730 WILSON WAY STOCKTON, CA 95205 1 STOCKTON,CA 95201 Phone: Contact: Phone: Contact: P)EXCHANGE 45' Pagel /1 TPID=1005559 Dccal-06-01093 Lisp-T1109718 TRMLER ti "I1' 24079 1•Q 1107202 7/10/2006 Mon T13 �N Drivcr Notes: $725.00 PER TRAILER*$35.00 FUEL SURCHARGE @ ONE 45 TLR-EXCHANGE 5. 0 0 Waste Tire Manifest Form for Electr0lic Mata Transfer (EDT) TIRE PROGRAM Iq: WCF SITE SUFFIX:-61(if applicable,from CIWMB Form 647) MANIFEST#: M - cility Is Tri-C Tire,Inc.as shown on the top f this form. TRAILER: f,l rop offap !rc ! P'ck # TRUCK#: 1 ��,SLATE#' � .LpECAL#: - QRIVEnR LICENSE#___ ___:_— (If Oppilcablo,from CIWMB Form li4e)LOG#: L_- Hauler Exemption: ❑ Government ❑ gdoultum ❑ LEA Exemption 0 Common Cartier Part 2:Load Information:Check one: Up ❑Delivery If pllcable,chock one:❑Import ❑Export Imp/Exp Location: Load Specifics: intended Use for Tires: 0 Retread 1214RCycle ❑Fuel 13 Disposal Tire Count Measurement:❑Whole Tire Count ❑Cubic Yards ❑Weight In Lbs 0 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 B: Count Rate Total Tractor: Count Rata Total Other Product C: Count_ Rate—ther Product A: Count Rate Total Total Trailer: Count Rata Total ,Q Other. Count Rate Total Sub-Total f: Count Rate Total Sub-Total 2: Count Rale Total Purchase Order# Cash Amount Check Amount Check# I certify that unde penalty of perjury nderthe laws of the State of California hat the Inf matiovided a ve Is true and eor r © Facility Rep sentatl Name(Print) Facility Repre tative's Sign ure Date Confidentiality Claim(applicable to all parties listed on above):The Information provided in Parts 1.It,and III of this form should be considered confidential,proprietary,and/or trade secret.In accordance with Title 141 CCR,Section 17041 aseq,should any member of the public request disclosure of this Informalloni I request that CIWMB contact me of tfie address and the telephone number above. Eloctronic Reporting to CIWMB:Td-C,Ina has been authorzed by CIWM>jto participate In the Waste and Used Tire Manifeet PDT etattronic reponing program,On behalf or the customer hated on thle Form,Tri-C Tire,Inc,will eiectronlcally transmit to CIWMS all required Information from this manliest form. I certify that under penalty of perjury under the laws of trig State or California that the Informatlon p vlded above Is true and correct in addltion,I am aware that falsification of this information may result in suapenslon,revocation,ar denial of to of Was re Hauler I'll, pursuant to Pubile Resources Code section 42960 and mey result In civil pe up 00 day,pe violation or administratl p per vloi n per day as described in Public Reso�ode Sectlon 42892. Drivers Name(Pr nt) rivers gnature Date ,CJ �W Dara