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California Integrated Waste Management Board <br /> :: CA Uniform Wase and Used Tire Manifes PO Box 1259, Sacramento,CA 958128 <br /> . Manife�syt Numbeii <br /> �_ XAMPLiW 23 IVI G04 ! <br /> State of Calit0310 INSTRUCTIONS ON BACK <br /> ClWM�6�-y6�4y7(03!63} ' <br /> Mauler (optional-Address Label) _ <br /> Inc Up. <br /> t Business Name LA-3 1 ="�'� -., ,! "'A '•� { , � �� <br /> O'out�e a t is 1 Address <br /> City, State, Zip <br /> Pe ivory <br /> _ Hauler's Business Phone �� --W�� LF—, <br /> _ <br /> (include area code) L 9 =--,L <br /> I f Hauler Exemption (if applicable) <br /> ❑ Government,❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number F ❑ Agriculture ❑ Common Carrier/ <br /> Back Haul <br /> 1� ! Ez— <br /> ] Eo le)❑ In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential, proprietary, and/or trade secret. In <br /> accordance with Title 14,CCR, Section 17Q41 et.seq,should any member of the public request disclosure of this information, ! request that CIWMB contact <br /> me at the address and telephone number above. <br /> I certify that under penalty of perjuryunder the laws of the State of California that the information provided above is true and correct. In addition,I am aware that falsification of this <br /> information may result in suspension,revocation,or dental of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil <br /> penalties up to$25,000 per day,per violation or administrative penaities up to$5,000 per viol€aticr�per day as desk€cribed in Public Resources Code section 42962. q / <br /> Driver's Name riot) Driver's Signature Date <br /> T <br /> -11: T£ E IMIPLE- - F. - E �M r ' <br /> (optional-Address Label) - <br /> �+�ti ts["-t�=� j.J�-� _ "` •»..�''s b `� ""{''-_'1�....�-r _.� --- 1` it /!] f �-- <br /> Business Name Facility's Business Phone (include area code) <br /> t <br /> Number&Street Address <br /> t , <br /> _ ❑ Address Same As Hauler <br /> IL -- l r ❑ Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> (�J - –� EJ Passenger El Oversize C] Retread/Reuse <br /> [�U2 <br /> Tire Program ID Site Suffix ,maycle <br /> ( )r c :PSD" .>:: 'E, ❑T–Yuck [I Other <br /> El Fuel <br /> .- <br /> '� t�fkto{i��'tCe�urtE -. {gk# �c-ki�3s <br /> 1folt me Cr sbi.+x 1R s wefgltt o T EEE •EEI ElDisposal/Landfill <br /> ?` 111 i I <br /> Comment Area <br /> 1 13 Ici [F- <br /> FlConfidentiality <br /> Claim: The information provided in Part I and Part li of this form should be considered confidential,proprietary,and/or trade secret. <br /> 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 <br /> contact me at the address and telephone number above. , <br /> I certify that under penalty of perjury under the laws of the State of California that the information`provided above is true and correct.In addition,I am aware that falsification of this <br /> information may result in civil penalties up to$25,000 per day,per viofalion or administrative penalties up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. <br /> Representative Name (print) Representative's Signature .Date i 32876 <br /> Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ _� <br />