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,as Thys Court <br /> acramento, CA 95828 $ <br /> h: 816-388.2093 Fax: 916-381-5412 <br /> BRANNON TfRE <br /> BRANNON-ALPINE YARD 7 -3730 WILSON WAY <br /> 1624 EAST AVE. STOCKTON,CA 95201 <br /> STOCKTON, CA 95205 77 �� <br /> Phone: Contact: raw <br /> Phone: Contact: Pagel / 1 <br /> PXCK UP 45''pRAYC,ER <br /> �M <br /> 'IFIIx1405559 IkaeY=4b-01093 Lisc�IP09718 � <br /> ®M <br /> 23330 <br /> 1107202 6/6/2006 Tue <br /> TB BOBC �N <br /> Driver Notes: PICK UP 45 TRAILER <br /> 1-1 <br /> tOT <br /> Waste "fire Manifest Form for Eiectr i is Data P aelnsoecf (EDT) say) <br /> TIRE PROGRAM ID: = <br /> SITE SUFF Q <br /> MANIFEST#; M L� 0 Facility is Tri-C Tire,Inc.as shown on the top of this form. <br /> TRAILER: O Drop oft (if pplica ee P P' k <br /> __STATE7r LIC PLATE <br /> TRUCK#:, (t appllcsble,from CIWM6 Form 64a)LOG#:L^-^_.�----- <br /> DRIVER LICENSE# --^ -- <br /> Hauler EXemptit)n: ❑ Gov®rnment Agriculture ❑ LFA Exemption E3 Common Carrier ort Imp(Exp Location: <br /> Part 2:Load Information:Check one: ick Up O Delivery If c e n Fuel ❑0lsposal�Impoci O Exp <br /> Load specifics: Intan�ded Use for Tires: ❑Retread <br /> Tire Count Measurement~LI Whole Tiro Count q Cubic Yards 17 Weight In Lbs ❑Weight In Tos appIlceble) <br /> Other Product Counts By Type(If <br /> Tiro Coins CY TYPO Other Product A: Count Rate Total <br /> passen6er Count Rate Total Other Product B: Count Rate Total <br /> Tuck. Count Rate' Toil Other Product C: Count Rate � Total--- <br /> Truck. <br /> Tractor. Count Rata Total Rate Total__— <br /> Trailer: Count Rate Total <br /> Other Product A: Count <br /> Other, Count J Rate Total— -- Sub-Total 2: Count Rate Total <br /> Sub-Total is Count Rate_ _ Total Check Amount Check# <br /> Purchase Order It Cash Amount <br /> I eettify that under penalty of perjury un r the laws of the State of California t t the inion etion p d above is true and cornet; ^ 6 (,r <br /> �-•�-� r' � 6 <br /> CD 9 <br /> FacUlry presen e's Signature Dateuld be f/� <br /> ' <br /> Facility Rep senlaiive's t e(Pant) <br /> confldeadalRtY Clalm(9PPItcable to CCR Sates lin eo on clove),should Information <br /> mese provided <br /> in Partspublic rcqu request dtIII <br /> of turc form <br /> r m 5 Inde <br /> tormadonlrequaet thaidered aC^MIME proprietary, <br /> me at thlor e <br /> crcrot.In accordance with TIU 1 <br /> address and the telephone number above. <br /> Electronic Reporting to cIWMB:Tri-C, whlas�ero�Gity�bn rby nitto clvvmB participate <br /> requirred Information from thio manifest form. elec1ronlc raportinp program•On behalf of the <br /> customer listed on this form,Tri-C Tire, <br /> 1 certify that under ptnalty of perjgry under the laws of the Slate of Cellfomie that the Tim <br /> Hauler Pros drod00 Pursuant to Public is ime and Re o=Os C0(10 section 42960I am aware tand IMay uresult to civil <br /> S up to 000 r day, er viola Uon or adminlstra pe Ili 0 per viol per day as described In Public Resou�s Code Section a28B2. <br /> Informatlon may result in suspension,revocation,or denial of rentwo of Waste Tlrm Hautaf R <br /> P <br /> Drivers Name Print) <br /> Drlvere gnat a Date <br /> � <br /> 6°ar°-*? <br /> d - <br /> I <br />