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OLEO '°N W '- 7 '8l 'add aW1, 1 P;AI ;3;� <br /> Pickup Receipt <br /> 15505 Spring Ave pickup Date. 10/30121312 <br /> Santa Fe Springs, GA 80670 <br /> Hauler and End Use Facility EDT Manifest#: 1686874 <br /> Truck: 454505 EDT Trip Log#: 409861 <br /> License Number: State; CA/9071284 <br /> State: GA Store No.: CN19112 <br /> Decal: 12-04046 EAGLES NEST HARLEY <br /> 13900 S HARLAN RD <br /> LATHROP, CA 95330 <br /> Telephone#: 2010/941-0420 <br /> THD: 1497832-01 <br /> 1 ITEM I OTY <br /> 1 Trailer: 12499 <br /> 1 <br /> Whole Tires _ _ 66 <br /> Total: 661 <br /> I cel <br /> ;i(y that under penalty ar perjury under the Iowa of the State of I certify that under p®naity of perjury under the lays of the Elate of <br /> Callftlrnia that the inform®tion provide:!above is trwi and correct. California chat the Informailon provided above is true and correaL In <br /> addltten,I am aLvare that falsill"imiion of Ihls Information may result In <br /> suspension.revocation,or denlV or renewal of the We,ste Tire Hauler <br /> Reglstratlon purawint to Publlc Rstaources Code section 42960 and may <br /> result In civil penali:e5 up to S25,000 per day,par violation or <br /> adrn.nismilivry penaltou up to$5,000 per violation per day as descriaed <br /> in Public ft16ource5 Code 9actlon 42962. <br /> Generator Signature Driver Signature <br /> russell bough JORGr� SOTELO <br /> Confidentiality Claim:The information provided on this fonr should be considered onffjoenbal,proprietarr�y,endlor trade <br /> C Data 7. *ecret-In accordance with Title 14,CCR,5actten 17041 etsoci,should any mmrnber of thti public request discloaure of this <br /> information,I raquQr�t that CnlRacycle contact we tit the address and telophone number above. <br /> Elaotrais R porting to CalRoeycla:Lakin Tire Worst nae been authorized by calRecycle to pwtitipata in the Waste rind <br /> Used Tiro Mcn fest EbT alez-tronl4 reporting pregr9m,On behalf of the customer listed on this form,Ltikin Tire Most will <br /> electrorlleally transmit:o CalRaryolb ail ragwrod informetfan from this mantfant, CalRacycle has approved the Lakin Tire <br /> West EDT form for use within the Weatq lire Manifest system i=DT program, <br />