|
GARDNER!DIRKSEN Fax:12098248855 May 27 2005 16:18 P.01
<br /> CaAtominIntegrated Waste Management Board
<br /> r nd �C � ` ed T$rM�� G
<br /> PC Box 1859;sacr9mento,CA,958121259
<br /> icN X M P �.• E 3 Manifest Number
<br /> State of California w 1 2 t a
<br /> MB 547(03103} INSTRUCTIONS ON BACK _
<br /> �I..� --rv,-, qq,,,,-r•: M.+(. 't-i�;��i� �j� ��� ``� pJ"�?L'�C�t ,3'' `v 'h ,� ` ,
<br /> �" t, r ', z l"Jl1i. � � t1 � ,t�, s ,,;,$'n ;tea",1, ��f���,.��..t.u:. �. "tLjta�i•� '�fut�e�ta,. tv' � a�::
<br /> a i x z ' ESR 1E�F (,ptlq�t+l Addr6sS L.9J21) —(
<br /> •+�� 1� � �U81r}t359 {�a"ltTt�ll4 ^� tl .
<br /> „ k ' `
<br /> City, Sime,.zip `
<br /> l �•
<br /> ( ;�;F n _ - , Haulers Business Phone r 1 w
<br /> f4ei t �ffi1�`vc4 (include area code) \ /
<br /> Pr r,
<br /> Haule,Exemption•of applicable)-
<br /> 1 ❑Government❑LEA Exempt
<br /> � IL
<br /> Load Date (MM/DD/YY) Log NumWr
<br /> ❑Agriculture ❑Common Caner/
<br /> I Back flaul
<br /> Irfd.lCate(it applicable) Transh .
<br /> License PF to R mber State Decal Nurttbdr _
<br /> pConfidentiality Claim:The information provided in Pact t and Part It of this form should be considered confidential,proprietary,and/or trade secret.Ir
<br /> accordance with Tiiie,14,;:CGR.Section 1700 et.seq,should;any.tneft0rof thepnbi(c request'discIcsure of this information,I.request;hat.CIWM13.Co►ijact,
<br /> MG at the address and:terepho6t nbmb+er above:.
<br /> I certify that•undsr penalty-of perjury under the laws of the State of California that the;nformaj on provided above is(rue and correct, tri addition,jam aware thatfalsifleation of this
<br /> information may result in zumenslon,revocation,or denlal of rpriewa)of the Waste Tire Haule.r'Ragistration pursuant to Public,Resources Code section A2980 and may result in civil
<br /> penaltle=up to 525,000 per.day,per violation or adminiatratr pon.a111e5 up to$6,000 per vlolanpn per day esA Cribed in Pgbec Reno na Code;notion 42982
<br /> ' ', r/• - �t,. o
<br /> [Driver's Nsflte"'^15 ,rint Driver's Signature Date
<br /> •"',p
<br /> f +
<br /> kh
<br /> I"gp1ioriq!-Address Lada!)
<br /> Business Name Facility`s Business Phone (Include area code)
<br /> Number&Street Address
<br /> Y Address Same AE Mauler
<br /> l f i,_} l 1 1 r i ,� t � l I l r t f [ � P;.( I i t 1 � , ❑ cnangc o'Address
<br /> City State Zip Code --
<br /> x. Tire Types.and.Amounts intended Use '
<br /> ❑ Pass®nger ❑Oversize ❑Retread/Rouse
<br /> Tire Program ID Site Suffix
<br /> R>cyr la
<br /> r `v '
<br /> P t*o_ ea a 7 r da s ck ❑Other Q Fusi
<br /> DisposayLarldfiti
<br /> rtaeirtr�tih k --
<br /> Lt`� "Y , Comment Asea`
<br /> Y 9il` N �_a. YS•A SYSt,a e1dGB�.rv`J.^�•l_.�1 �� �__ _.w.r...r..,..�. ..�__ ._,�.....•.�„ter— __
<br /> C7 Confidentiality Ctairn: The information provided in Part I and Pali 11 of this form ahouid be considered confidential,proprietary,and/or trade secret.
<br /> In accordance with Y'itle 14.CCR,Section 17041 et.seq, should any member of the public request disclosure of this information; 1 request that QWMB
<br /> contact me at the address and telephone number above.
<br /> I certify that udder penalty of perjury under th'9 lava of the State of Califomis th4t the jnfonnatior provided.above is true and correct.in addition,1 am aware that falsification of this
<br /> iniormatlon may resuh In civil penalties up to$25.000 per day,per violation or administralive penat6e3 up to 55.000 per violatlon per day as described in PubQc,Resources Code
<br /> section 42982.
<br /> y.
<br /> `,..entative Name (print) RepresentatiVe's SignatWre Date 32876
<br /> Toga Frf.Le 1-856-896-0600 / www.ciwm, b.ca.govrrireks/
<br /> \While:CIWMB Copy Pfr!;:Tre Dealer/Gworator/and-Use Facility Copy Yellow:Hauler Copy —1
<br />
|