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J UL.C4.CU00 1VJ-4JHI'I I Kl—l. I lKt NO.73 P.7/9 <br /> the Recycling <br /> 1588 Thys Court <br /> 'acramento, CA 95828 <br /> 'h: 916-388.2093 Fax: 916-38112ills, DOWN <br /> h.. <br /> BRANNON-ALPINE YARD BRAIQNON TIRE <br /> 162 EAST AVE. 3730 WIT,SON WAY <br /> STOCKTON, CA 95205 STOCKTON,CA 95201 <br /> ?hone: Contact: Phone: Contact: <br /> Pagel / 1 <br /> rPID-1005559 Decal=06-01100 Lisc-69C48165 rib., <br /> �o> <br /> 1107202 7/5/2006 Wed ')� 23988 fON <br /> Driver Notes: $725,00 PER TRAILER+$35.00 FUEL SURCHARGE Q ONE 45 TLR-EXCHANOB <br /> d (} <br /> RIC <br /> b-pyl ?61! <br /> Waste Tire Manifest Form for ElectroIhic Data Transfer (EDT) <br /> TIRE PROGRAM ID: SITE SUFFIX:��(If applicable,from CIWMB Form 647) <br /> MANIFEST#: M -_ iE Facility Is Tri-C Tire, In as shown on the top of this form. <br /> TRAILER: �Drop off � S (if app able Pick # <br /> TRUCK#: b TAT : LI PLATE# � 1 DECAL#. <br /> DRIVER LICENS # � f applicable,from CIWMl3 Form B48)LOG#:lam- _„__._--— <br /> Hauler Exemption: ❑ Government ❑ Agriculture L3 LEA If applicable,chacone:Common <br /> ❑Export Imp/E <br /> n Carrier xp Location: <br /> Part 2:load Information:Check one:QVick Up`g( ry PP <br /> Lead Specifics: Intended use for Tires: ❑Retread ' Recycle EI Fuel O Disposal <br /> Tire Count Measurement-U Whole Tire Count ❑Cubic Yards ❑Weight In Lbs ❑Weight In Tons <br /> Tire Counts By Type Other Product Counts By Type(if applicable) <br /> Passenger. Count Rate Total Other Product A: Count Rate Total <br /> Truck: Count Rate Total Other Product R. Count__- Rate Total <br /> Tractor: Count Rate Total Other Product C: Count Rate Total <br /> Trailer: Count Rate Total Other Product A: Count Rate Total <br /> Other: Count Rate Total <br /> Sub-Total 1: Count Rate Total Sub-Total 2; Count Rate Total <br /> Purchase Order# Cash Amount Check Amount Check# <br /> certify that under penalty of perjuryunderth tawsrpf the State of California th9a;EK <br /> band correct <br /> �e cD I 1 ^d <br /> Facility Representative's Nam rint) ature D6le <br /> Confidentiality Claim(applicable to all parties listed on above):The information provided In Porta I,11,and III of this form should be considered confidential,pmpdetary,and/or trade <br /> secret.In accordance with Title 14,CCR,Section 17G41 et.esq,should any member of the public request diaetosure of this Iprormatlon;I request that CIWM8 contact rile at the <br /> address and the telephone number above. <br /> F-toctronlo Raportln0 to CIWMB:Trl-C,Inc.has been authorized by CIWNIB,ito participate In the Waste and UW Tire Manifest EDT electronic reporting program On behalf of Lha <br /> ;ustomer listed on Ih16 form,Tri-C Tire,Inr-will electronically transmit to CIWMB all required infortrlatlon from this manifest form- <br /> certify that under penalty of perJury under the laws of the State of Catltomla that"Information provided above Is true and carr et.in addition,I am aware that falsification of this <br /> n/ormatlon may rosull In sus ton,revocatbn,or dental of renew r the Waste Tire auler Repletratlon pursuant to Public aRFeurces <br /> s Code section 42960 and may result In civil <br /> �enaltbs up to i26,o00 par ay per I tlon or administrable 9 up to 00 r vi talion per day as describe P Code Sedlon 42962. <br /> Driver's Name fin t / Drivers ignat re ate <br /> V ate, <br /> I <br /> � e <br />