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Rim <br /> rd-c TAre Recycling � <br /> 1588 Thys Court <br /> ;acramerill CA 95828 {� <br /> Ph: 916.388-2083 Fax: 816-3815412 <br /> rBFANNON TARESRANNON-ALPM YAR.0 SON WA'Y <br /> 1624 EAST AVE, STOCKTON,CA 95201 <br /> STOCKTON, CA 95205 <br /> Contact: Rm <br /> Phone; Contact: Pagel /1 <br /> PTCK'ITP TIC�CE <br /> Latin <br /> TpM.1005559 Decal-o6-01100 Lisrr9C48165 0 <br /> ®N <br /> TB - 23 7 LNIN <br /> "7 <br /> 1107202 "11r2o, 6 'Mu <br /> Driver Notes; $725.00 PER TRAILER Q ONE 45-EXCHANGE <br /> k' <br /> Nb U <br /> Waste Tire Manifest Form for Electrbnjc Data Transfer (EDT) <br /> TIRE PROGRAM ID; / L D .2 =!2 2- SITE SUFFIX:ol—tlf applicable,from CIWMB Form 647) <br /> MANIFEST M M-L e-ffe-cility Is Tri-C Tlro,Inc.as shown on the top of this form. <br /> TRAILER: (3 Drop off,_ ! (If aVcabla) <br /> ❑ Pick up# <br /> TRUCK:j—q _STATE: c�R LIC P1ATE#: <br /> D ��. DECAL_#:Q,( <br /> DRIVER LICENSE#——_ _——�-—— (!f applicable,from CIWMB - <br /> Form 648)LOG M.L !— — <br /> hlauler Exemption: ❑ Government JWAGriculturO 0 LE4 Exemption Q Common Carrier <br /> Part 2:Coad Information:Check one: ick Up Q Delivery if applicable,check one;0 Import 0 Export Imp/Exp(_ocatian: <br /> Load Specifics: Intended use for Tires: D Retreq/n Recycle ❑Fuel ❑Disposal <br /> Tire Count Measurement:❑Whole Tire Count ubic*@ftis ❑Weight in Lbs 0 Weight in Tons Ilcable) <br /> Tire Gouttts By Type other Product Counts By Type(if app rel <br /> Thr ; Count Rate Total Count <br /> Passenger. Count Rate Total Other Product A: Rate To <br /> Other Product 13: Count Rate,_ Total <br /> Total <br /> Tractor. Count Rate Total Other Product C: Count Rete, Total <br /> Trailer Count_ Rate Total <br /> Other Product A: Count <br /> Other: Count Rate Total <br /> Sub-Tata11: Count Rate Total Sub-Total 2: Count Rate Total <br /> Purchase Order# Cash Amount Check Amount Check# <br /> certify that under penalty of perjury under the laws of the State of Califomla that the information provldad above Is true and correct. <br /> ��� <br /> Facility Representative's Signature Date <br /> kFacifility Representative's f3ame(Pr1nt) meta and/or trade <br /> tlatlty Clalrn(apppcable to aM partio listed on above):The Infooatlon provided In Parts 1.11,and III of thls form should be considered conrdentlal,proprietary, <br /> secret In Balt dance (ap Title 14,CCR,Section 17041 et8eq,should any member or the public request disclosure or this Informatlon;I request that CNJMt3 contact me at the <br /> address and the telephone number above- ram,on behalf of the <br /> Efectrontc Reporting to CIW?AS:Tri-C,Ina has been authorized by CiWMS to participate In Lha waste and Ugptl Tire Manlfeat EDT electronic reporting program, <br /> customer meted on this farm,Tri-C Tire,hit will electronically transmit to CIWMl3 all required Information from thIS manifest form. <br /> i cel that under penalty of perjury under the laws or the Stats of COO la that the Information provided above is true and correct in addition,I am aware 80 falsification r of this <br /> informationnal may p oS2 sults pat days,spec vlovdo tion,of denial <br /> if renewal �th ss�00 eNvloiallon auler plef day estration a described nursuant to uPiubl Pic ublic s Cods Code e�siection a2A62d may result in civil <br /> o i Oate <br /> Driver's Name(Print) Rriver's Signature <br /> r� <br /> z <br />