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pr •. California Integrated Waste Management B a d ' CA`Uniform Waste and Used Tire.ManlfeS P0 Box 1259, Sacramento.GA 95&f2#259 ", Manifest Number i" XAM � L � state of Gahlornia' clwMe-647(03/03) \INSTRUCTIONSON BACK ." hauler ��ogfienp!'-Address�a6ei) I B iress Name) L)J , SE > ✓� �' s 4 Address— pity, ddressCity, State,ZIp- Hauler's Business Phone , ex r (include area code) S t Hauler Exemption (if applicable) 0 _ ❑ Government ❑ LEA Exempt .Load Date (MM/DD/YY) Log Number ❑,agriculture ❑ Common Carrier/ Back Haul. 3 j IfldlCate_(if applicable)❑ in-Transit T� � .License Plate Number - - State Decal Number ❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential, proprietary;and/or trade sec(et. 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 contact "meat the addYess and telephone`number above ;-� " 1-certify that,under'perialty'of perjury under the laws of the State of Califomia that the information provlded above'is trueandcorrect: In-add ition,I am`Aaee that falsification of this 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 penaltics up to$25,000 per day,per violation or administrative penalties up to$5;000 per violation p_er day as described in Public'Resources Cod_a section 42962. inI7 Driver's Name /int) - Driver's Si nature i"�.: Date (opfional-Address`Label) lr + t ✓ is.l •! l' i C i' -1"a-,r b C_.•.s Business Name Facility's Business Phone (include area code) ' t _ +~. ' . J. Number&Street Address ❑ Address Same As Hauler p 1 E]Chang Of Address I f l l -] I 1 l- 1 I I I I I I i I___ l L±, I I I / [ .t =-tet I. I City State Zip Code Tire Types and Amounts Intended Use ❑ Passenger ❑ Oversize ❑ Retread/Reuse Tire Program IDSite Suffix p Recycle Truck I i I ❑ Other ❑ Fuel IffDisposal/Landfill Comment Area ❑Confidentiality Claim: The information provided in Part.I and Part Ii of this form should be considered confidential,proprietary;and/or trade secret. 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 contact-me at the address and telephone number above. .. 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 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 section 42962. Representative Name (print) Representative's Signature ` Date 32876 Toll Free 1-866-896-0600 / `www.ciwmb.ca.gov/Ti6res/ �.