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JUL.24.2006 10:46AM TRI—C TIRE N0.73 P.9/9 <br /> fire Recycling <br /> 1588 Thys Court <br /> Sacramento, CA 95828 <br /> ?h: 916-38B-2093 Fax: 916-381-512 SWUM <br /> i0 S- <br /> BRANNON-ALPINE YARD DT30 WV N TIRE <br /> 1624 EAST AVE. 3730 WILSON WAY <br /> STOCKTON, CA 95205 STOCKTON,CA 95201 <br /> �r <br /> Contact: Phone., Contact: ®m <br /> Phone: Pagel /1 <br /> PEXCHAN'GE 45' <br /> TRAILER Qm <br /> TPID=1005559 D=1-06-01100 Lisc-9C48165 <br /> ::sr 24276 <br /> 1107202 1/17/2006 Mon 1'D �r <br /> Driver N T,L SURCHARGE Q ONE 45 TLR-EXCHANGE <br /> Waste Tire Manifest Form for Electronic pata Transfer (EDT) <br /> TIRE PROGRAM ID: 1 ��a, SITE SUFFIX: (If applicable,from CIWmB Form 647) <br /> MANIFEST#: M <br /> Aj— Q Facility is Trl-C Tire, Inc.as shown on the top of I f rm. <br /> TRAILER: Q Dropopfap llcabla)U Pick u # p <br /> TRUCK#: _ _STATE: LICPIATE#: �f��DECAL#: -5� ��— <br /> DRIVER LIENSE# ____ (if applicable,from CIWMB Form 648)LOG#: <br /> Hauler Exemption: Q Government ❑ Agriculture ❑ LEA Exemption ❑ Common Cerrier <br /> Pert 2:load Information:Check one:IZK I�Up Q Delivery >Ppllcable,check one:❑import ❑Export Imp/Exp Location: <br /> Load Specifics: Intended Use for Tlres: ❑Retread cycl6 ❑Fuel ❑Disposal <br /> Tire Count Mgasurameint:❑Whole Tire Count Q Cubic Yards ❑Weight in Lbs ❑Weight In Toes If applicable) <br /> he Counts t3y type Other Product Counts By Type( pp ) <br /> .Tire Counts Count Rate Total Other Product A: Count Rate Total <br /> Truck: Count Rate Total_ Other Product B: Count Rate Total <br /> Rate Total Other Product C; Count Rate Total <br /> Tractor: Count Other Product Count Rate Total <br /> Traller: Count Rate Total <br /> Other: Count Rete Total <br /> Sub-Total l: Count' Rate Total Sub-Total 2: Count Rate Total <br /> Purchase Order# Cash Amount �Check Amount Check# <br /> I ceRi>Y{hat under penalty of peri under the laws of the State of California that the Information above Is true and correct. / 1© <br /> ..e Date <br /> Facility Represents Iv 's Name(Prim cc ty Repre ativeId Signa urs <br /> soc1,if,and III of thli rm AhOU <br /> netd In alaalitV Claim <br /> (apAth TIUebI M1, all CCR,parties <br /> listed <br /> ted on bove):The seq.should <br /> anyamemtion ber of the publlced In Beque t dlarJ sura of his into i lydequeserad tthatt CIWMB contact me atlthetrade <br /> address and the telephone number abovo. <br /> WMB to participate Ip the Waste end used The Man fest EDT electronicroponlne program,on behalf of tie <br /> Electronic Reporting to CIW MB:TA-C,Inc.has been authorized by CI <br /> customer listed on this form,Trl-C Tire,Inc.will electronlcally transmit to CIWMB ell required Information from this manifest form. <br /> I ceN1Y that udder penalty of penury undertha laws of the State of Callfornla that the Information provided above Is true and correct.In addition,I am aware that falsification of this <br /> Intorrnation may result to suspenslon,revocation,or denial of renewal of the.Waste Tire aular Registration pursuant to Public Resources Code section 429Ad end may result In civil <br /> Pe ties up to B, o par of y,per violatlon or adrnlnls t tl p to ,000 violation per day as described in Public Resources Code Section 42962. <br /> Driver's Name(Print) rive ign Date <br /> '0C Dal rf <br /> �oe� <br />