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CA Uniform Waste and Used ' Camomiarniegrated Waste Management Beard ; Y Tire Manifest PO Bog 1259, Sacramento,CA 95812 E X A M P t_. E 1 2 3' Manifest Number - ciwM�"7 oyo 1 INSTRUCTIONS ON BACK [1�6 �1 r 7. i Hauler (option Address Label)' Business.Namel Address �1 .iU . (A-) City, State, Zip .: Hauler's Business Phone (include area code) �• � j - c Hauler Exem' tion (if applicable) ❑Govemment❑LEA Exempt Load Date (MMIbD/YV) Log Number ❑Agriculture ❑Common Carrier) 4Back Haul Lf Indicate(if applicable)❑In Transit License Plate Number State - Decal Number ❑Confidentiality Claim: The information provided in Part I and Part It of this for p 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 CIWMB contact me at the address and telephone number above. I certify that under penalty of parjury under the taws of the State of California that the information provided above is trice and correct. M addition,I am aware that falsif€cation of this information may result in suspension,revocation,er.denial of renewal of the Waste Tire Hauler Registration pursuant to Pub€id'Resources Code section 42960 and may result in civil penalties up.tto$25j000 per day,per violation or administrative penalties up to$5,000 per 1violation�er day as dgescribed in Public Resources Code section 42962. Driver's Name(print) Driver's Signature r Date rp Etional-Address Labe!) T Business Name ` Facility's Business Phone.(include area code)) Number&Street Address ❑Address Same As Hauler L� �f C"I _.t I 'I„ •� t~, J t' Change Of Address City State Zip Code Tire Types and Amounts Intended Use 5 5 -1 I ( I ❑ Passenger ❑oversize Tire Program ID Site—Suffix C]Retreadlf3euse ��•� •m ❑Recycle Truck ❑Other ❑Fuel f Yf �' `'"".I •m �Disposal/landfill i Comment Area r ❑Confidentiality Clalm:.The information provided in Part I and Part II 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,t request that CIWMB contact me at the address and telephone number above. I certify that under penalty o€perjury under the Paws of the StaleofCalifornia that the information provided above is true and correct.In addition,I 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 Cafe section 42962. / Representative Name(print) &eRepresentative's SignatRate 32V6 ■ Toll Free 1.866-896-06001 www.ciwrnb.ca.govMresl �. ■ White:CIWMB Copy Pink:Tire Deafer/GeneratodEnd-Use Facility Copy Yellow:Hauler Copy