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r- lilcmia Integrated Waste Management board -Ca form Waste anUsed d Ud Tire Manifest .Ql3oMa59. Sac Number CA CA Uni ■ ■ EXAMPLE 123 ItA� 20��3175� 4YYii 4 luteol (03 ) INSTRUCTIONS ON BACK aw�st;-647 e4z low Hauler (opfioslal Address Label) Business Nar1iel uo,k S U-) L4 _ i,,� Address city, Slate, Zip Haulet's Business Phone (inetude area Hauler Exemption (if applicable) r ' �� C� SJ L ; — t✓ I t� , ❑Government ❑LEA Exempt Load Date (MM/DON ) Lag Number _ _ El Agriculture ❑ Common Carrier/ back Haul Indicate(if applicable)❑In Transit E-s �� ,� License,Plate Number _ State - Decal Number []Confidentiality (i R Section 17041 ett.seq,should any member ofrovided in Part I and Part 11othepublicc request disclosure of this infoermation,I request that lCIWM13 c6ntactor trade secret-ln accordance with Title 144,,Cis form should be cons�dered cOidn C , me at the address and telephone number above. 1 certify that under penalty of perjury underthelaws of the State of California the information provided above is true and lic Res to addition.I am aware that falsification It this' information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Cade section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000.0er violation per day as descri4ed in Public Resources Code section 42962. �.��l �� •. `� � 4� ,,�>f-r�� Date Driver's Name tint) Driver s Signature F(c�,i7ii(ynal- Address Label) l - RED Business Name Facility's Business Phone (include area code) Number&Street Address ❑Address same As Hauler jC]Change Of Address il r "& Zip' 1State City _ Tire Types and Amounts Intended Use ,l ❑Passenger ❑Oversize ❑Retread/Reuse ='EJ] Tire Program IQ Site Suffix ❑Recycle [Truck 1 LLL��111 ❑Other ❑Fuel [Ti .� .� ❑f7isposaVLandfill Comment Area ❑Confidentiality Claim: The ihformation,provided in Part I and Part ll of this form should be considered confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of.the public request disclosure of this information,I request that CIW M8 contact me at the address and telephone number above. I certify that under penally of perjury under the laws of the State of California that the information provided above is true and correct.In addition,E am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. _ � { ' Representative Name.(print) Representative's Signature Date 321375 . Told Free 1-866-896-0600 ! www:CiwMb.ca.gov/Tires/ Whitq:CFW MB Copy Pink:Tire DealedGeneratodfnd-Use Facility Copy Yellow:Hauler Copy