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Picku <br /> p Receipt <br /> 15305 Spring Ave <br /> Santa Fr Springs, CA 90670 <br /> Hauler and I_rid Use Facility Pickup hate: 7114!2015 <br /> Truck: 423468 60T Manifest,#: 1101426415 <br /> License Number: State' CA/91734829 EDT Trip Log#: 525690 <br /> State: CTA <br /> D6cal: 15-06936 <br /> Store No.: F1036j6 <br /> FIRESTONE TRACY <br /> 940 CENTRAL AVE <br /> TRACY, GA 95370 <br /> Teleph onO:209/221-7164 <br /> TPIO: 1694854-01 <br /> PMllr;e $278aleTi " QTY <br /> r <br /> Total: - = , <br /> 209 <br /> ofifcr that under penalty of p rook d ab,r the trU of the Stale. I�ert"I that under penalty Of perjury under the laws of the state of <br /> Cttlifornl�that the Inf9rmt�tlon provld6d ebove IS iruc and correct. <br /> CalJfornia that thl`information provlpwd above Is true and correct, In <br /> ad¢Iltlon•I am aware that Fai Iiicatiun of this infarmatlon may result In <br /> Syspension,revocation,or domal pt renewel of the Wztsto Tare f l2wler <br /> f�ogistrat1011 pursuant to Pubife RL360=96 Code section 42960 and mey <br /> rbsillt in Civil penalt;ps Up to$25,000 per dray,per vlolwilon or <br /> Ndrrinistr0live penajUan up to$5,000 Or violation par day as described <br /> In Public Resources Code Sectioli x2862. <br /> Generator signature <br /> kenneth Driver Signature <br /> JOI:RGE SOTELO <br /> rn <br /> V <br /> r <br /> cDafrr Cont'Identialityr Claim:The Information provided on t111s form 4hould be ccnsitlerWd confideritlel,prapfiehi ,and/ortrada <br /> �A St3q mt.In acrordanee with Title 14 CCR boct;on 17041 eLseq,6h6Uld arty mem66r, of the y�' <br /> Inlp,'rnetlon. I rBttUesf that CalRecycle aonlact me at thu ed•drese public request t�IRClosurFi <br /> a11d telephone nultlbor above, of'this <br /> Ele d Tiru aePort E to C-10ROCYCIO:Lakin Tire West hay btlmn euthorizmd by CafRFacycle ro arUcipate In tFle Waste end <br /> Used lira Manifest QST etectrenlr reporiinq pr rem, p <br /> electrOniCylly irangmll to CalRecycle aft reqult'eddiinformOticrl��m°his mdnifesi.CUStomerliBlydon CallR ecycte 18gg Lakin Tlru West will <br /> West L52OT form for usy withln the Waste The lvtwnl <br /> fest Systiom EDT program, approved the Lakin Tirt <br />