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*"W* rw <br /> Pickup Receipt <br /> 15305 Spring Ave <br /> Santa pr,Springs, CA 90670 Pickup Date: 611612015 <br /> Hauler and End Use E�jcility <br /> EDT Manifest#: 1101409$45 <br /> Truck: 4234'x8 EDT Trip Log#: 522223 <br /> Cleanse Number., State:CA9F34829 <br /> St6tQ: CA <br /> Decal: 15-06936 Store No.: FI036J6 <br /> FIRESTONE TRACY <br /> 940 CENTRAI. AVE <br /> TPACY, CA 95376 <br /> Tal®phone#; 209/221-7164 <br /> TPID; 1694854.01 <br /> ITEM <br /> Trailer:WSTZ002772 QTY <br /> Vllhole Tires -- -�� <br /> 269 <br /> Total: 269 <br /> l aisrtlty that under penalty of perjury under tho lows of the State of I(Wr(Ify thul under penalty of perjury undor the laws of thu FWiG or <br /> Culitbrnlru that the information provided aktove lFj true and correct. C0111"Ornia thell IN inforrnition provided above Is true and Correct, In <br /> addition, I am awarrd thwt'I31sification of this Information relydy Mutt in <br /> suspeizsicn,revocation,or doniol of renewal of the Waste Tire MM411or <br /> Registration pumuanl tG pu011C RO-sources Code section 42960 end ntay <br /> rasult in civil penaltlgg Up 10 E?6Z0 Char doy,por violatton or <br /> administrative penalties uo to$5,000ppur violation per day as descrIbod <br /> In Public Rosources Code Section 42uQ:'. <br /> Generator Signature <br /> Driver Signature <br /> k�snneth JORGE UOTELO <br /> Confldentiallty Claim;The inforrmi lon providod on this form should be considered confidential,propriatmr ,andior trade <br /> �ci�taT secret.M eccardan00 with Titter 14,CCR,Swcticn 17041 ot.seq,should any member of the public reque6t disclosure of this <br /> informadon.I request that CalReaycle Contwat Meat the addreen and lolephone number above. <br /> ro <br /> Electronic Reporlln do CalRdoyniu,(Lakin Tire West has bean rauthoFzed by CaAecycle t,o partial alo m the Waste and <br /> Used Tira Manifest EDT elecimmic ivportlng program.On behalf of the customer Ilsied on thio form,rakin Tire West wits <br /> olectronlcally transmtt to CalRecyclh all required Information from this manifest CalRec ole hilum upprovad the Lakin Tire <br /> West EDT form for use within thin Waste Tim Manlfeel Systam EDT program. <br />