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California integrated Waste Management Board <br /> GA Uniform Wa-ce and Used Tire Manifes PO Box 1259, Sacramento,CA 95812-1259 ■ <br /> • =� AMPLE 123 - Manifest Number <br /> EX <br /> NUNN <br /> State ofCalifornia INSTRUCTIONS ON BACK 1 203481 <br /> CIWMB-647{03103) <br /> lValFV <br /> -IP Hauler � L3 t(option l-Address Label) <br /> Business Name3' <br /> iiit tiat�tel,,. 1t1y Address <br /> Peffftry city, state, zip <. ,y r { <br /> o ex rt <br /> Hauler's Business Phone <br /> t3ttt�sr31 rAiataf�.de�nftjt (include area code) { s J ) I! ..� lz� ! ; <br /> L �? Hauler Exemption (if applicable) <br /> ' f. I1 —.= [11Government E] LEA Exempt <br /> _ 1 <br /> Load Date (MM/DD/YY) Log Number [f Agriculture ❑Common Carrier/ <br /> 1Back Haul <br /> ! 13 117 � 31 v �. Indicate 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 ot.seq,should any member of the public request disclosure of this information, I request that CIWMB contact <br /> 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 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 <br /> to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day asdescribed in Pubtic Resou�rcesCodepsection 42962. <br /> ff 5 4f .� 3' f V '1.\.l! L I �.✓�+...^-�'Y l i f�r� �..-/*��If -�-"'.� / <br /> Driver's Name rint Driver's Signature i` Date I 3 <br /> IF, Tf -OSA TIRE 6 <br /> TO Be 0QMPLeMQV1WPM$ <br /> (optional-Address Label) l _ <br /> Business Name Facility's Business Phone (include area code) <br /> - f-t <br /> Number&Street Address <br /> € ' <br /> F]Address Same As Hauler`' <br /> T— � f �'` 1� I ;„_f l ` I I I �� I 'T ! I f l I ❑Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> i I —;� ❑ Passenger ❑ Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix •m •m <br /> ecycle <br /> T t: Ckoti*4nr ' [}Truck ❑ Other <br /> . :. ❑ Fuel <br /> V[►tufneiC YatS tint in Tbns - •m ❑ Disposal/Landfill <br /> Comment Area <br /> ❑Confidentiality Claim: The information provided in Part I and Part€1 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 penally 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 violation 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 32876 <br /> Toll Free 1-866-896-06001 www.ciwmb.ca.gov/Tires1 <br />