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Tri-c Tire Recycling 8588 Thys Court Sacramento, CA 95828 Ph: 916-388-2093 Fax: 916-381-5412 916.388.2093 Service Address ,Site-#1541 Billing Address Cust# BRANNONALP' BRANNON-ALPINE YARD BRANNON TIRE 1624 EAST AVE. 3730 WILSON WAY STOCKTON, CA 95205 STOCKTON, CA 95201 Phone: Contact: Phone: Contact: _© PEXCHANGE 45' Panel / 1 fP(D=1005559 Decal=06-01100 Lisc=9C48165 TRAILER SIte:TP1D k SchedfDate�.. 'Day Tlme Clerk: a�-.Driver Route:;. P.O.#' Order#; Type, 1107202 7/21/2006 1 Fri I I TB 24381 1 =� Driver Notes: $725.00 PER TRAILER+$35.00 FUEL SURCHARGE @ ONE 45 TLR-EXCHANGE Waste Tire Manifest Form for Electronic Data Transfer (EDT) TIRE=PROGRAM ID:_Lj 1_7 a�%� SITE SUFFIX: ( (if applicable,from CIWMB Form 647) MANIFEST#: M 1-, 24� C3 Facility is Tri-C Tire, Inc. as shown on the top of this. TRAILER: ❑ Drop off (if applicable)0 Pick up# —I) TRUCK#: 7 __STATE: LIC PLATE#: � � DECAL#: -�a ZL° DRIVER LICE SE#________ (if applicable,from CIWMB Form 648)LOG#: L---___^_ Hauler Exemption: ❑ Government ❑ griculture ❑ LEA Exemption ❑ Common Carrier Part'2: Load Information:Check one: Ick Up ❑Delivery If applicable,check one: ❑Import ❑Export Imp/Exp Location: Load Specifics: Intended Use for Tires: ❑Retread G3-Rule ❑Fuel ❑ Disposal Tire Count Measurement: ❑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 Trucks , Count Rate Total Other Product B: Count Rate Total Tractor: Count Rate Total Other Product C: Count Rate Total Trailer: Count Rate Total Other Product A: Count Rate Total Other: Count Rate Total Sub-Total l: Count Rate Total Sub-Total 2: Count Rate Total Purchase Order# Cash Amount Check Amount Check# I certify that under penalty of perjuryrider the laws of the State of California at the information provided above is true and correct. Facility Representative' ame(Print) Faci i Represen five's Signal:Oe Date Confidentiality Claim(applicable to all parties listed on above):The information provided in Parts I,11,and III of this fortrilsfiould be considered confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information;I request that CIWMB contact me at the address and the telephone number above. Electronic Reporting to CIWMB:Tri-C,Inc.has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program.On behalf of the customer listed on this form,Tri-C Tire,Inc.will electronically transmit to CIWMB all required information from this manifest form. I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of rear ewahof the Waste-Tire Fiaule(Registration pursuant to Public Resources Code section 42960 and may result in civil e a testy to$ 5, 00 er da r violation or administraliv2 alti ` p �f p 2_ ` p�l y,p/ 1 �peFi� ; p�tb$5;00.0.per v 3tion per day as described in Public Resources Code Section 42962. Driver's Name(Print) "Driver's/Slignature 'Date ,r w ',, d•t° arp..