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JUL.L`f.[-VCJU iu-"DrIl l I Rl-l. I II\L IYu. (z'L .r.G/7 c Tire Recycling 1588 Thys CODA ,acramento, CA 95828 MUM f 916-z88-2493 Fax: 916-381-5412 1.Q2.�► it`3u�t; BRANNON TIAL; 3730 WILSON WAY STOCKTON, CA 95201 ` STOCKTON,CA 95201 Phone:209-993-2928 JA AE C Contact:209-993-1358-F?REI) Phone:209-462-5398 Contact: �m PEXCI3ANOI�45' Pagel / 1 TpD.1005559 Dccb1= 6-01100 L.isc=9C48165 TR '9: INN22755 WASE LN 5/15/2005 Mon � TS -� brivcrNpt�: $725.06 PEk TRAILER-F-XCHANGE E- Waste Ti r � e�ForM� or Electrcinic��4a Transfer (EDT) TIRE PROGRAM ID: SITE SUFFIX d_ (if applicable,from CIWMB Form 647) MANIFEST#; M -j•—:2 r — O Facility Is Tri-C Tire,Inc,as shown on the top of this fa . 7RAlt,ER: ❑ Drop off (if applica I Pick u - TRUCK#:L -- TATE,C LICPLATT:I GI LD c'EGAL#: �; TRUER LICENSE — — —^--- (if applicable,from CIWMB Form 648)LOG#: L_ -- 1.3auler Examptlon. ❑ Government t7 griculture ❑ LEA;Exemption O Common Carrier Pett 2:Load Information:Chack 01`1e:4�po Up ❑Delivery 11applica4le,check one:O Import ❑Export Imp/Exp Location'. Load_Spealfics: intended Use for Tires: ❑Retread (cycle ❑Fuel a Disposal Tire Count Measurement'❑Whose Tire Count O Cubic Yards ❑Weight in Lbs ❑Welflht in Tone, Other Product Counts 13y Type(if applicable) Tire Counts By Type Other Product A: Count Rete Total Passenger. Count Rate Total Other Product B: Count Rate Tota{_ Tm�; Count Rata 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 Tota{ Sub-Total 2: Count Rate Total Cash Amount _ Check Amount R�Check# Purchase Order# correct.S I L I certify that u r pena©f 1381TP dder the laws of the State of California that the information provided above�is tr a Jd s 6 Q 4L�.JphDate Facility presenteil e' Name(Print) �Fadlltyseniati Signature Conftderttialir CIa1m(apprirabl¢t all parties fisted on above):The Informatlan provided In Parte I,U,and 111 of This form sh be considered canildentlat,proprietary,end/or trade secret.In a-arcisgce Wim Tftle 14,CCR.Section 17041 etseq,should any member of the public request disclosure of this Information;1 request that CIWMB contact meat the address and the telephone number above. electronic Reparttng to CIWMB;Tri-C,Inc.has been authorized by CIWW to participata in the Waste and Used Tlro Manliest EDT electronic reporting program,On behalf or the customer listed on this form,Tii-C Tire,Inc.WIl elearonlc^transmit to CIWMB all required information from this manifest form. rp re that cn of that the ded above is e and I terrify that u ay reWl In uspens oon.revocatlon or den a of renewal oSW6 Of ff 06,Waite TlraNaatlon s Rpag{ctru pursuant o Public R ourcas C06 sectlon 42060 end matey f suit ntctvll Ulforrnat on eta s r pe u �2 00 r day,per vlelalon or admin7ID)rilve u ��' 006 FIS elation per day as described IPublic Re�ures6 Code section 42962. Dr'vers Name(Print) Signature Data �naeQr