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California Integrated 1Naste Manageme t Board <br /> f rM Wa 'te. alnd ,Used Tire. Manife ';-.pO Sox 1259, Sacramento;"CA 958 2-1259 <br /> ,■ �CA Ung o. X <br /> ¢, X A.M P, .L 2 3 Manifest Number }; <br /> '-"State"ofCalifornia.':-INSTRUCTION50N BACK -'*' •"" �` �`'��• "''13 <br /> - <br /> CNJMB-647(03!03} ' - <br /> Hauler (api'fot�a Address Wr.j sir ' <br /> Business Name <br /> Address _ <br /> 14 <br /> d� <br /> Ci y,-StatO' "Ztp <br /> Haulers Business Phone <br /> (include area <br /> Hauler EXemptl4n (if applicable) <br /> ❑'Government ❑"LEA"Exempt <br /> 'Load Date (MMIDo/YY) ", tag Number . <br /> ❑Agriculture ❑"Common Carrier/ <br /> 1: � .. • .• . . . ,Back Haul " . <br /> �• ; <br /> -Indicate if a ficable <br /> R� ( pp )❑ in Transit <br /> License:Plate Number, State _,:.Decal Number <br /> .:"❑Confidentiality Claim:The information proyided.in_Part I and Part ll.of"tfiis,form should be considered confidential;":propfietary,"and/or trade secret. In <br /> w, accordance wittt;Title 14 CCR Sei Eron 1ZD41 of seq should any,member of.the public request disclosure of this information '1 request ihaf CIWMB contact <br /> me afi:fhte address and telephoni :number:"above k* fs ,i <br /> Fcertify that'under"perialty.of perjury under the laws of the State of California that the"information provided above is true and correct. to addition I"am-aware that.falsificatien-of this <br /> information.may result"in suspensioi6evocation,or denial of renewal of the Waste Tire-Hauler Registrafion-pursuant to Publrc.Resources=Code.secfion 42960 and'may result in civil <br /> penalties.up.to$25,000 per day,per violation'o�'administratiJe penalties up tv$5,000 per violation per day:as described in,Public'Resources Code section:42962..' <br /> -'.-Driver's Name(print). - river's Signature <br /> Date <br /> d iional=Addres `L 1 <br /> s abe - <br /> ( P - <br /> .°�Busines:S Name F <br /> t _ acilit s:Business Phane includ' +" <br /> Y ( e a ea code? <br /> 1'1_Number&Street"Address <br /> Address Same As Hauler <br /> �'i. �g <br /> ❑-Chan e Of Address <br /> C4', State" 'Zip Code !, Y <br /> Tire Types and Ani. dnts ,;:.: Intended.tJse r <br /> J" ❑"Passenger ... ❑Oversize , <br /> ❑ Retread/Reuse <br /> Tire_Program ID':� Situ Suffix <br /> "❑ FtEcycle" <br /> E„ Truck ❑'.Other " <br /> (~" El Fuel a <br /> ri m isposal/Landfill s, <br /> F Comment Area <br /> ;❑Confidentiality Clairt'm:'The'information provided in Part I and Part II of this form should be' considered confidential, proprietary,and/or.trade secret. <br /> 1 i In accordance with TitIe.14,:CCR;Section"17041 etaeq,should'any member of the:public request disclosure of this.information,:I request that"CIWfJIs" <br /> ,contact me,at the address'and telephone number above ` <br /> l ceriify that"under penalty of perjury under the laws,of the State of Califomia that the`infotmation"provided above rs true'and correct:In addition,I am aware that falsification'of this . <br /> information may result in civil penalties up to$25,000 perday,per violation or administrative-penalties`up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962 } <br /> rF <br /> Representative Name(print) -.Representative's Signature- „Date •32876 <br /> I <br /> . ToII Free 1 `866-896-060Q 1 ::www.ciwmb.ca:,gov iresl ;s .= '._ <br />