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(DAM" 7W <br /> Pitrkup Receipt <br /> 15305 SprincJ Ave <br /> Santa E®Springs. CA 90670 <br /> Hauler and End Use Facilfty PIekup pate: 8/2S/2015 <br /> Truck; $23468 <br /> EDT Manifest#: 1101452802 <br /> License Number: State:CA/9F3.4829 EVI"Trip Log#: 530893 <br /> State: CA <br /> Decal: 15.06936 Store Ne.: F1036J6 <br /> FIRESTONE TRACY <br /> 940 CENTRAL AVE <br /> TRACY, CA 9537$ <br /> Telephone#:209/221-7164 <br /> TPID: 1694654-01 <br /> ITSm <br /> Trailer; s3� - Q7Y <br /> Whole Tires <br /> -- -- <br /> 167 <br /> ---�-- Total -z_ 167 <br /> I certify that under Penalty mlty of perjury under above <br /> 13 the State,of I certify[hat und+ar ponalty of perjury underthe lain or the ytNte of <br /> California that thg Inlormatlon provided abovo Is true <br /> and end corrc3ot. <br /> CalifernlW that tho Information provided above Is true and earrmt. In <br /> addtitlon,t am awwrO that Nb5ifiicatl0l of this Information may result In <br /> suspenuian,revocation,qr drnfai of renewal of the VVw4te l Ire Mauler <br /> Re9istrbtion pursue M to Public Resources Code section 42960 and ma <br /> result in clvll panalties up to 8:25.000 per dny,per violation or y <br /> �dm'"rrativa penalties up t0$5,000 pr viot7llon per day as d%cribed <br /> In Public Resources Code 5tir:tlon 42262. <br /> Generator Signature <br /> Jeremy Dri Ver$igllature <br /> J&1 GE SOTELO <br /> K914 <br /> Pa4 ConfidIn entiality Claim:Tho In(ormallan plbvided on this farm 9houtd be considered xnfidential,proprietaryry and/er trade <br /> information, ordaneQa with Title 94CCR,faction 17041 of eq should any member UI the puDIIC request diaclggurtl n/this <br /> _4 <br /> � rcqu st that CalRouycle contt�a me at thy address and ielephone numoor above. <br /> electronic Rv ar'ting to CaIR <br /> used Tire Mani( b "e reP L»kin Tlra West has boon sruthorizmd by CalRecycte to pad tt ptltG irl lhu Waste and <br /> mat E T elmcrronlc repbtting program.Ori b0half of thu customer Iiated on this farm,lakln Tlro West will <br /> eh3ctrunicaay transmit to CulRecycle all required Warmatlot from thin manifest. Capecyt:le has approved the Lakin Tlro <br /> Went EDT form for use within the Wasto Tire MaMilbG11 SyaO�m EDT program. <br />