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JUL.24.2006 10:46AM TRI-C TIRE N0.73 P.9/9 <br /> Irlre Recycling <br /> 1588 Thys Court <br /> Sacramento, CA 95828 <br /> Ph: 916-388-2093 Fax: 916-381-5412 9� 3 <br /> BRANNON-ALPINE YARD BRA730 WON TIRE <br /> 3 <br /> 1624 EAST AVE. 3730 VV'1ZSON'WAY <br /> STOCKTON, CA 95205 STOCKTON,CA 95201 <br /> .rte <br /> Phone: Contact: Phone: Contact: ®ID <br /> PEXCHAN'GE 45' Pagel /1 <br /> am <br /> Tf 1TRAYLERD=1005559 Ural-06-01100 Lisc-9C48165 ti <br /> 24276 c <br /> 1107202 7/17/2006 Mon <br /> Driver IN T.L SURCHARGE Q ONE 45 TLR-BXCAANGE <br /> Waste Tire Manifest Form for Electronic pata Transfer (EDT) <br /> TIRE PROGRAM ID: SITE SUFFIX:i2 (If applicable,from CIWMB Form 647) <br /> MANIFEST#: M L^ j Q Facility is Trl-C Tire,Inc.as shown on the top of I <br /> TRAILER: 13Drop off ft ep llcable)❑ Pick u # p <br /> TRUCK#: _STATE: LIC PI-ATE#: - ��z DECAL#: -� — <br /> DRIVER LI�ENSE#,_—__ (If applicable,from CIWMB Fort 649)LOG#: L_-� _^--- <br /> Hauler Exemption; Q Government ❑ Agriewlture ❑ LEA Exemption ❑ Common Carrier <br /> Pert 2.Load Information:Check one:M-ck Up n Delivery If �pllcable,check one:❑Import ❑Export Imp/Exp Location: <br /> Load Specifics: Intended Use for Tires: ❑Retread cycle ❑Fuel ❑Disposal <br /> Tire Count Measurement:❑Whole Tire Count to Cubic Yards ❑Weight in Lbs ❑Weight In Tons <br /> Tire Counts By Type Other Product Count$By Type(if applicable) <br /> Passenger Count Rate Total Other Product A: Count Rate Total <br /> Truck: Count Rate Total Other Product B: Count Rale Total <br /> Rate Total Other Product c; Count Rate Total <br /> Tra : Count Other Product A: Count Rate Total <br /> Trailer: Count Rate Total <br /> Other: Count Rate Total Sub-Total 2; Count Rate Total <br /> Sub-Total 1: CountRate_ Total <br /> Purchase Order# Cash Amount _Check Amount Check# <br /> I certil that undpr penalty.of perj under the laws of the State of Callfornta that the Intormatio©vided(hove Is Prue and correct. <br /> Date <br /> ��—Ralllty Represents v 's Name(Prin'� ac ty Repro ative's Signa ureConfidentiality <br /> In iiality Claim <br /> wllh TIUeb'14,CCR, ties listed 7041 et seq.should on abelvd):The ormati( bar oMprovif the publlced request dlscJ sure or his Informoonl,11,and III ofthIl mlthoUld be nl request thatCIWM5 Contact me at the <br /> sectrade <br /> address end the telephone number above. <br /> an Electronic <br /> lomat listed Reporting ohloorCIIWM.TAe,,Inc.c. has <br /> electronically trap mit to CIWMBCIMS 10 pe l required informatioarticipate in the n from and lthis Manifest form.d Tire Manifest EDT electronic reporting program.On behalf of the <br /> cus <br /> m,Tri-C <br /> I ceNfy that udder penalty of penury underthe laws of the State of Callfomla that the IrlformaUon provided above Is Irue and correct.In addition,I am aware that ralsifice0on of this <br /> Intofmaaorr may result In suspension,revocation,or denial of renewal of the aste Tire $tiler Registration pursuant to Public Resources Goge section 42980 and may result In civil <br /> pe ties up to 5. 0 per d y,per violatlon or adminls t U p to ,000 r violation per day as described IO Public Rea 5 Coda Section 42962. <br /> Driver's Name(Print) rive ign pate <br /> u� 'D <br />