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JUL.C4.CrJt7ty 1V0 45H1"I I HI—U 11HE NO.73 P.Big .re Recycling 6588 Thys Court Sacramento, CA 95828 Ph: 916-388-2093 Fax: 916-381-$412 aim w.rtt BRANDON-ALPINE YARD EIFANNON TIRE 1624 EAST AVE, 3730 WILSON WAY STOCKTON, CA 95205 STOCKTON,CA 95201 Phone, Contac Phone: Contact; t: rw- P$XCHANGE AS' 1 Pagel /I TPiD=1005559 Decal&,06-01093 Liscdl'P09718 TRAILER —c, ti inII V Q 24079 )♦Q 1107202 7/10/2006 1 Mon 1"l3 'N Drivcr Notes: $725.00 PER TRAILER+$35.00 FUEL SURCHARGE Q ONE 45 TLP,-EXCHANGE 0 0 V waste Tire Manifest Form for Electro;nlc Data Transfer (EDT) TIRE PROGRAM 14:- WC! 2 SITE SUFFIX:_' 1(if applicable,from CIWMB Form 647) MANIFEST#: Mculty Is Tri-C Tire,Inc.as shown on the top f thls form. TRAILER: G,l rop offap !rc 1 P)'ck # TRUCK#: 1^ SlA7E f2pECAL#; - QRIVER LICENSE# ___ __ (Ifapp,l{cable,from CIWMB Form 64A)LOG#; L_--- Hauler Exemption: ❑ Govemment ❑ grlcultum ❑ LEA Exemption ❑ Common Carrier Part 2:Load Information:Check one:ZPU Up ❑Delivery If plicable,check one:❑Import ❑Export Imp/Exp Location: Load Specifics: Intended Use for Tires: D Retread ycle la Fuel O Disposal Tire count Measurement:❑Whole Tire Count ❑Cubic Yards ❑Welght In Lbs O Weight in Tons Tire Counts By Type Other Product Counts By Type(if applicable) Passenger. Count Rate Total Other Product A: Count Rate Total Truck: Count Rate Total Other Product B: Count Rate Total Tractor: Count Rata Total Other Product C: Count Rate Total Trailer: Count Rate Total Qther Product A: Count Rate Total Other. Count Rate Total Sub-Total 1: Count Rate Total Sub-Total 2: Count RateCheck# otal Purchase Order# Cash Amount Check Amount I certify that unde penalty of perjury rider the laws of the State of California hat the Inf mation provided a ve is true and correct. r © �r C5 4 Facility Rep sentati Name(Print) Facility Repre tative's Slgn ure Data Confidentiality Claim(applicable to all partles listed on above):The Information provided 1n Parts 1.11,and III or this form should be considered eonfldential,proprietary,and/or trade secret,in accordance with Title 14,CCR,Section 17041 et-seq,should any member of the public request dlucloaure of this information;I request that CIWMB contact me at the address and the telephone number above. IWMB to participate In the Waste and Used Tire Manifest RDT electronic reporting program On behalf of the Electronic Reporting to CIWM13:Td-C,Inc.has been authoriized by C customer listed on this form,Tri-C Tire,Inc.will electronically transmit to CiWM6 all required lnfonnatien from this manifest form. I cenlfy that under penalty of perjury under the laws of file State of C911rornla 4hal the Informatlon P vlded above Is we and correct,in addition,I am awaro tat falsification of Mls Information may result in suspenalon,revoeaUon,or denial of ren of West re Hauler Istralion pursuant to Pubge Resources Code section 42960 and may result In civil pe up�(Prant�) e violation or administraU p per viol n per day as described in Public Reso� a Section 42ee2. Drivers Narivers nature Date SCJ 8W Ogtp3 y a�