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OLSVIN V ' l �IOZ -8l -Jdy amll panl ;);� <br /> Pickup Receipt <br /> 15305 Sprnq Ave Pickup pate: 9/2512012 <br /> Sante Fe Springs, CA 90670 <br /> Hauler and End Use Facility ED7 Manifest#: 1863675 <br /> Truck: 454505 EDT Trip Log 0: 406731 <br /> Liccrise Nuimbor: State; CA)9D71284 <br /> State: CA <br /> Decal: 12-04045 Store No., CN19112 <br /> EAGLES NEST HARLEY <br /> 13500 S HARLAN RD <br /> LATHROP CA 95330 <br /> Telaphon w�:200/941-0420 <br /> TPID: 1497832-01 <br /> rrEM QTY <br /> Trailer: 941975 <br /> Whale Tires_ - 258 <br /> 1 <br /> — — Total: 2581 <br /> I cnrtiry that under penetty of penury under the laws of the State of I certify that under penalty of perjury under the laws of the Stale of <br /> Califotnla that the Iii Ion provided above Is true and collect. Galiforni2i that the irrformstion provld4d above is true and correct. In <br /> Addition,I am awai-e that falsification of this information may result in <br /> suspension,revocation,or denial of renewal of the Waste Tiro Hauler <br /> Reglstration pursuant to Public Resouroaw Gude aactloh 4.060 and may <br /> result In olvii penaltiop up to$25,000 per day,per violation or <br /> administrative penahles up to S5,000 per vialabon per day as deii;iio d <br /> in public Racources Code 6oati0h 42962, <br /> Generator Signature Driver Signature <br /> thomas JORGE SOTELO <br /> r ice' <br /> r i � <br /> Cnhfidentialfty O lin:The information provided oh this form should be considered confidential,proprietaryry,andlor trade <br /> Y-31C flat r secret.In aocordanoe with Title 14,CCR,Section 17041 et.seq,shrauJ any member of the public request dlsclosure of this <br /> Inforrnatfon,I request that CalRacycle contavf me®t the address and tslephone number above <br /> j"ftf%mElautmnic Rapott n to calRaeycle:Lakin Tiro West has been authorized by CalRecyda to p�aarticipate in the Waste and <br /> Used Tire Manifest Ell electronic repoting prograrn,On behalf of the customer ilMoV on 11116 4orm,Lakin Tire Nest will <br /> alaetronimily transrrvt to tralRecycle all rNuired information frorn dila menlfest. CalRecyde has approved the.Lakin Tire <br /> West EDT Ill for use within the Waste Tire Manifest Slyetam EDT program. <br />