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164MW aw Pickup Receipt <br /> 16305 Spring Ave <br /> Sarna Fe Springs, CA 90670 Pickup Date: 7/28/2015 <br /> Hauler and End Use Facility <br /> EOT MansiFeSt#. 1101435616 <br /> Truck; 423468 EDT Trip Log#: <br /> 527360 <br /> License Number: State: CA/9F34829 <br /> State: CA <br /> Decal: 15-06936 StOre No._ FI086J6 <br /> FIRESTONE TRACY <br /> 940 CENTRAL AVE <br /> TRACY, CA 95376 <br /> Telephone#:209/221-7164 <br /> TPID: 1694$54-0'1 <br /> rRV <br /> M <br /> iler:42241 - QTY <br /> ole Tiros <br /> los <br /> 4 <br /> -`��'—'- Total= � - <br /> 212 <br /> 1 certify that undror pen;+Hy of perjury under the IaWF,Y thn State of I <br /> California lhut the infom)atton provided above is true and correct. allfor that under penalty of Perjury under the laws of the"tale of <br /> California that the Information prcvlded above Is true and cOnt�ct, In <br /> addlilun,I am aW,ItG that falsiflcatlon of thio information May result In <br /> suspension,revoeallol),Dr dental of rene"i of the Waste Tlry Hauler <br /> Regls ration pursuaint tb Public Resoureof Code section 429ffo and may <br /> result in civil ponalti"up W$25,000 per day,per violation or <br /> administrative ponaltle,c up to$6,004 per violation per day as tloVcrIbed <br /> In Puhlie Regourcoo Code Section 42982. <br /> Generator Signature <br /> Diver Signature <br /> jamea JORGE u''`OTELO <br /> .�1 e <br /> �4 '^ <br /> Conflelantiality Chslmt The information prpvided on thle form should be consldood 4onflldentlal, ro ie <br /> e�" Daty�,` secret,In aceorChnan vulth Title 14,CCR.Section•17041 et-se should an member of Ih p dtyi losur trete <br /> information, I raque l that CalRecyele eonttaat and o4t the address and telephone nUnit)or C bpvs_Ilc request disClot3una of this <br /> =° Electronic Reporting to CalRecycko,L.aIdh Tire Wcst has been authoriaod by CoMeeycie to partirtpete In ihm Waste and <br /> LJOW Tire Manifest EDT electronic foporting Program_on b!;half of the OM)Omer haled on this form,l.altln TIi�1 Wast will <br /> ole-tronleally transmit to CalRepycle all required Information from I:M6 mtvnbesl CarRecycle has approved the Lakin Tire <br /> West EDT form for urge Within the Waste'Lire MankSt Sys%m EDT pro9rdm. <br />