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+� Recycling <br /> 1588 Thys Court <br /> Sacramento; CA 95828 ; <br /> 'h: 916-388-2093 Fax: 816-381-5412 Sim= <br /> BRANNON-ALPINE YARD NRANNON TIRE <br /> 1624 EAST AVE. <br /> WILSON WAY <br /> STOCKTON, CA 95205 STOCKTON,CA 95201 <br /> .7 <br /> Phone: <br /> Contact: Phone: Contact: W,9 <br /> PXXCffANGE,451 Pagel /1 <br /> Tpli=1005559 Decal-06-01093 Uso-TP49718 TRAIUM <br /> �m <br /> 23350 � <br /> 1107202 6/7/2006 1 Wed F1111111N <br /> Driver Notes: 5725.00 PER TRAILER AT ONE 45 TLR•EXCHANGE <br /> 0 C&# ua) F <br /> Waste Tire Manifest Form for Eiectr6nic Data Transfer (EDT) <br /> TIRE PROGRAM ID: SITE SUFFIX: ��l of applicable,from CIWMI3 Form Cal) <br /> MANIFESTO: MD Facility is Tri-C Tire,Inc.as shown on the top of this fo <br /> TRAILER: Drop off Cf 19J .�,� # �� G <br /> TRUCK#:LQ-__STATE: LIC PLATE#: 'T QF-CAL#: ' <br /> DRNER LICENSE#_—______ (if applicable,from CiWMB Fort 648)LOG#; L� _—_—__ <br /> Hagler Exemption: 0 Government EI Agriculture CI LEA;Exemption 0 common Carder <br /> Part 2:toad Information:Check one:I�, fa; up C1 Delivery Jap'pltcable,check one:C import ❑Export Imp/Exp Location: <br /> Load Specifiost Intended Use for Tiros: O Retread ecycla O Fuel ❑Disposal <br /> Tire Count Measurement:❑Whole Tire Count 0 Cubic Yards d Weight In Lbs ❑Weight In Tons <br /> Tire Counts By Type Other Product Counts By'rype(if applicable) <br /> Passenger- Count Rate Total Other Product A: Count Rat® Total <br /> Truck: Count Rat® Total Other Product B: Count Rate Total <br /> Tracior Count Rate_ Total Other Product C, Count _ Rete Total <br /> Trailer: Count Rate Total Other Product A: Count Rate Total <br /> Other. Count Rate Total <br /> Sub-Total l: Count Rate Total Sup-Tota12: Count Rate Total <br /> Purchase Order# Cash Amount _ Check Amount Check# <br /> I certify that under penaltyy�duty u d rthe taws of the State of Califomi that the information provided ova I true and correct, / <br /> L.J 1 h <br /> !� <br /> Facility Representative's t1j1imi(Print) facility Repir ntative's sig tura Date <br /> Conflclentlaoly Ctalm(applicable to all partits paled on above):The iqforrniVon provided in Parts I,It,and IiI of thiMan should be conaldered confidegtial,proprietary,and/or trade <br /> secret In accordance with Title 14.CCR,Section 17041 eteeq.should amy member of iM public request dlaclosure of this information;I request that CIWMB contact me at the <br /> address and the talephone number above. <br /> EleetronlC POPOCttng to CIWMB:Trl-C,Inc.has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program.On behalf of the <br /> customer listed on this torn,Tri-C Tire,Inc.will electronically transmit to CIWMB all required information from this manifest form. <br /> I certify that under penalty of periury under tete laws of the Statt of California'that the information provided above Is true and correct.In addition,I am aware that falsification of this <br /> Infonrnatlon may result in suspension,revocation,or denlal M renewal of the Waste Tire Haul,KRegistration pursuant to Public Resources Code eectlon 42960 and may result In civil <br /> Den~u 1 0 r day violation or edrnlnls pa a z u ,000 per Y�rallon per day sa described in ublie RtsourCes Coda Section 42862. <br /> �' ^A�-0,16 <br /> Driver's Name(Print) Driver' ignature Date <br /> ®r , <br />