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+ s California Integrated Waste Management Board <br /> CA Uniform Waste -and'.Used Tire Mai PO Box 1259,.Sacramento,CA 95812-1259 :0 <br /> ■ Manifest-Numbeer Q g <br /> EX' AME E 123 <br /> P" - '� � f: <br /> CIWVV <br /> eatCalifomia• INSTRUCTIONS ON BACK` - <br /> CIWMB-647(63!03) <br /> Ha1JAeropfioi�a , cii�ress Laaei} <br /> Business Namet,3: u <br /> Address - 7) u, <br /> City, Slate, Zip, <br /> Haulers Business Phone <br /> (include area code) <br /> '.i <br /> Hauler.Exemption (if applicable) <br /> ! ❑Government ❑ LEA Exempt <br /> m <br /> Load Date.(MM/DD/YY) LOg'NUmber [� Agriculture ❑ Common Carrier) <br /> Back Haul <br /> IndKate(if applicable)❑ In Transit <br /> License Plate Number " State Decal Number <br /> ❑Confidentiality Claim: The information provided in Part I and Part 11 of this form.should be considered confidential,proprietary;and/or trade secret. In <br /> accordance with Title 14',CCR,:Section 17041-et.seq,should any member of the public request disclosure.bf.this Information [.request that CIWMB contact <br /> me afthe address and telephone=nuniber'above :- '` ' `' <br /> rcertiiy that.under'penalty of perjury under the laws.of:the State of California that the information provided above 4s true and cbrrect. In addition,I am aware that ialsificaiien of this <br /> information may result in suspension,revocation,or denial 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 <br /> {day,per violation or ad"nistra_Live penalties up to$5,000 per violaliod"per`'d}ay as described in Public Resources Code section 4289162. <br /> A. <br /> '�'- - k }'�1/[ s�.+'��.r'' 3„_._-: <br /> Driver's Name Tint) Driver's Si nature. �y - _ .Date <br /> {optional;Address Label) <br /> Business Name . Facility's Business Phone (include area code) <br /> t. <br /> Number;&Street.Address <br /> _.❑Address Same As Hauler <br /> I ❑ Change Of Address <br /> City State.. Zip Code <br /> Tire,Types and Amounts - Intended Use <br /> F-1Passenger " ❑ Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix ,m <br /> Recycle <br /> L]Truck ❑Other Fuel. <br /> m ".❑ Disposal/Landfill <br /> Comment Area <br /> ❑Confidentiality Claim: The informaiton provided in Part I and Part 11"of this form"should be considered confidential,proprietary,andlor.trade secret. <br /> <.ln 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 informatlon provided aboye-is true and correct.In addition,I am aware that falsification of this <br /> information may result in civil penaltie§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 <br /> section 42962. <br /> k, f F dI <br /> Representative <br /> Name"(print) Representative's.Signature .Date x2876 <br /> ,. Tall Free 1-866-896-0fi001 . www.ciwmb,ca.govlTiresl <br />