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n <br /> r.Ca{forma Integrated Waste Management Board <br /> CA Uniform 'Waste and.-Use' d_ Tire .Manifest - PC Box 1'259, Sacramento,CA 95812-1259 ■ <br /> • k0 ,JEJXJA M.P FL E 1 2 3 Manifest Number <br /> StatClWM -64711ornia INSTRUCTIONS ON BACK - <br /> l • � 203414 <br /> CIWMB-647t03l03) ' <br /> Hauler • .. . -� <br /> USInCSS dame 4-_t 1 �.Y 1a. ` ;_ - ✓„ i ��.� :nM . <br /> I ti, 'W Address <br /> City, Mate, Zip ' = -r. . . Wit.- <br /> z Hauler's Business Phone ,. 1 _ <IN At <br /> (include area code)' <br /> HaUIBr Exemption (if applicable) <br /> ❑ Government ❑ LEA Exempt - <br /> Load Date (MM/DD/YY) Log.Number <br /> E]Agriculture ECommon Carrier/ <br /> Back Haul <br /> [Z[� _ Y <br /> �,, U- t�, ? ,. •-a `. • A {` - 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 1704.1 et.seq should ahv.lmemberL of the public request disclosure of this intormatlon I request that CIWMB contact <br /> m6.at the address and telephone numb' `above.: <br /> I certify that under penalty of'porjury under the laws of'the.State of California tliat the information provided above es true and corroct. in addition,'I am aware tHat falsification of this <br /> information may result in suspension,revocation,at 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 day,per violation or administrative penalties up to$5,000 per violation per day as descnb_ed,in Public Resources Code section 42962. <br /> t_ ! <br /> L. +- -+`. �'d� f - ff `-t-r'�1. �Z..r:. �._ r'� A <br /> Driver's Name(print) Driver's Signature � .�`': Date <br /> s <br /> 4 a r g; tr :il <br /> � �- <br /> g <br /> (optional AddretssLabel) <br /> eA <br /> Business Name Facility's Business Phone (include mea-codb) f <br /> / / <br /> Number-&Street Address: <br /> ❑Address Same As Hauler <br /> I.�I / I -�I L--L. 1�I- r 1 f- 16 3 1 I I f ^I' :I t I' f 1 I ! E !yl--� E I 1 t I ❑Change Of Address <br /> City State Zip Code <br /> Tire Types'and'Amounts <br /> ` ntended Use <br /> 117 ❑ Passenger ❑ Oversize. <br /> ❑ Retread/Reuse <br /> Tire Program ID :Site Suffix ' <br /> 221 rruck ❑Other <br /> Fuel W <br /> m ❑ DisposaVl_ ndfill <br /> Comment Area <br /> `. <br /> ❑Confidentiality Claim: The information provided in Part I and Part'll 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 /> 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 violation or administrative penalties up to$5,000 per violation per day as described in Public Resource's Code <br /> sectlon 42962. <br /> Representative Name(print) Representative's Signature Date 32876 <br /> M 4Toll Free 1,-866-896-06001 www.ciwmb.ca:aovlTires/ �� <br />