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---- '- J UL.L4.LLjuc) IU-L441-'11 1 I[',I <br /> Tire, itet;yclleig � tit z5b% <br /> 1688 Thys Court <br /> ;acf amento, CA 95828 <br /> 3h: 916-388.2093 fax: 916-381-602 <br /> BRANNON TIRE <br /> B ON-AL,PI F- YARD 3730 WILSON WAY <br /> 1624 FAST AVE. STOCKTON,CA 95201 <br /> STOCKTON, CA 95205 r_ <br /> Phone: Contact: ®m <br /> Phone: Contact: Pagel /1 <br /> pEgCHANGE 451 <br /> TRAILER <br /> TPIDr1005559 1=1 6-01100 Liscr9G48163 s� <br /> 2300 i <br /> 1107202 5/23/200ir TB 1. D <br /> Driver Notes: v <br /> r <br /> 0 <br /> Waste Tire Manifest Forth for Electronic Data Transfer (EDT)rm sal) <br /> TIRE PROGRAM I / / © -2 a O Z SITE SUFFIX:_9I Of applicable, <br /> MANIFEST#; -�t3 O O C3'�lity Is Tri-C Tire,Inc.as shown on the top of this form. <br /> TRAILER: ro off m (If applicable)[] Pickup# -- <br /> ES DECAL#: - ���-- <br /> TRUCK#:_L 2__-STATE:__ LIC PLATE#: �.� L <br /> DRIVER LICENSE#—�._--.—_._.— ((Itapplicable,from CIWMBFomtl346)l_OG#: l,_----..---- <br /> Hauler Irxetription: 11 Government p Agrlcultu LEA E mptlon ❑ Common Carrier <br /> Pert 2:Load Information:Check one:❑Pick Up ellvery If applicable,check one:p Import ❑ExPort ImplExp Location: <br /> Load Specifics: Intended Use for Tires: ❑Retread ❑Recycle ❑Fuel ❑Disposal <br /> Tire Count Measurement:❑Whole Tire Count ❑Cubic Yards ❑Weight in Lbs O Weight in ToIf s applicable)Other Product counts By Type( pP ) <br /> Tire counts By Type Other Product A: Count Rate Total <br /> passenger, Count Rata Total Other Product B; Count Rata Total <br /> Count RaC <br /> te Total Rate Total <br /> Tack: Rate Tots) Other Product C: ount Total <br /> Trader. Count Rate Total Other Product A: Count Rate <br /> Trailer: Count <br /> Other: Count Rate Total Total <br /> Sub-Total 1; Count Rate Total Sub-Total 2: Count �teCheck#-- <br /> Cash Amount —�1 Check Amount_� <br /> Purchase Order# under the laws of the State of California that the Information providod above Is tru nd correct. <br /> I cetttfy that under penalty of perju c <br /> U I <br /> nature Data <br /> Facility Rap <br /> aentativo' under <br /> (P nt) Facility form <br /> should g and/or trade <br /> Conftd nVa���11"Irm�{hPlIcabla TItle t a parties Section 17041 et.seq,a oon abova): u ld any mernberInformation vof the ided 1pUtACsrequ request disclos1,111,and III of ure of his Infomia4onconsidered <br /> l ie�lhatGlWMB conteet ma et tna <br /> secret In <br /> address and the telephone number above. ram.On behalf of the <br /> Efactro ic on ins o IWM:Tire,Inc.whaelebeen authorized ctronicattytransmit to C�wmD alGIWMS to l required IndPzte in formation from thls\rvalte,and dmanifest fTim orm. <br /> customer <br /> electronic reporting proA <br /> custotnthis <br /> I certify that under penalty of pedury under the laws of the State of Caffforr}}a trial the Inomtallon provided above Is true and licRact.In addition,I am aware that falsification r Of to s <br /> vravatfon or administrative p lose .00 p violet n per day as described In Pueilc Resources Code Section 42962. <br /> information may reaUtt In 6ysdpenslon,rovocatton ordenlai of renewal of the Weat The Hauler R091SVatlon pursuant to Public i1c Resources <br /> Code Mon on 42 and may ro9ultin civil <br /> penal to s,oQo per - — 1 <br /> � A //h Date <br /> Dr" o e Name(Print) Drivel's Signature <br /> °cro r <br /> � 9 <br />