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California Integrated Waste Management Board <br /> v_ a ■ <br /> CA Uniform e and Used Tire Manifest' 95812-1259 <br /> ■ Manifest Number <br /> WE EXAMPLE 23 ME�i - 4 <br /> state ofCalifornia� INSTRUCTIONS ON BACK M 5. 1 2' 0 3 ! <br /> CIWMB-647(031631 <br /> PMoMPLOWOOT <br /> Fqc" Hauler (Optional-Address Label) <br /> Business Namel UJ <br /> Irajr€ <br /> Address ; <br /> -- City, State. Zip <br /> O Exp "' l— I <br /> Haul <br /> er's Business Phone <br /> -. _ ff'auts"tc�e tf[�1•f�i� le:,=q'� ? � �° � � 1 — ( T'� '��' ` <br /> r (include area code) <br /> r i <br /> Hauler Exemption (it applicable) <br /> ❑ Government ❑ LEA Exempt <br /> Load,, at (MM/DD/YY) Log Number ❑Agriculture ❑ Common Carrier/ <br /> Back Haul <br /> zJIndicate(if applicable)❑ In Transit <br /> _License Plate Number State Decal Number <br /> 6Confidentiality 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 17041 et.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 Caiifornia 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 pursuanl to Public Resources Cade 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 described in Public Resources Cade section 42962. <br /> Driver's Name rint Driver's Signature "` Date <br /> 71F. � ° R tiaR :Q R <br /> motional-Address Label) � <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> ❑ Address Same As Hauler <br /> ❑Change Of Address <br /> f IL.rI– `JLY 11 <br /> City State Zip Code <br /> -- Tire Types and Amounts Intended Use <br /> ❑ Passenger ❑ Qversjze ❑ Retread/Reuse <br /> Tire Program ID Site SuffixF1 11 <br /> ,m El-Recycle <br /> (check only fit/ ` d Truck ❑Other ❑ Fuel <br /> Ihctl�Tit Cgt}rtt Fejcft in'1©i�13 . <br /> VcHum'e Q-ubieYard4s igkt in orfs e I _U -m E] Disposal/Landfill <br /> Comment Area ���I <br /> ❑Confidentiality Claim: The information provided in Part 1 and Part II 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 ialsificalion 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 1-866-896-0600 1 www.Ci.WMb.ca.govfTires/ <br />