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CA Uniform Waste and Used Tire Manifeb>< PorIntegrated Waste Management Board <br /> PO Box 1259, Sacramento,CA 95812-1259 <br /> WHEN= <br /> EXAMPLE 1 2 3 Manifest Number <br /> State of California <br /> CIWMB-647(03/03) INSTRUCTIONS ON BACK M 6 - 13 18 9 4 0 <br /> - <br /> R ; <br /> Ck Up Hauler (optional-Address Label) <br /> Business NamJ --�—� --- <br /> ,import from i C.' c (7 t <br /> {If outside California State/Count__ Address <br /> //v <br /> r i, <br /> i' <br /> elivery City, State, Zip <br /> - i <br /> Export to <br /> 7 <br /> I r Business Phone <br /> Hau e s us ess <br /> (include area code) ( ! ) f } <br /> 71 ' , , Hauler Exemption (if applicable) <br /> 1 ❑ Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> ❑ Agriculture Common Carrier/ <br /> Back Haul <br /> Indicate if a Il <br /> ( pp'cable)❑ In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidentiality 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 /> 1 certify that under penalty of perjury under the laws of the State of California that the information pr, ded above is truend correct. In addition,I am aware that falsification of this <br /> informatio'6;^may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler R stration pursuanJ'to�ubUC esources Code section 42960 and may result in civil <br /> penalties y to$25,000 per day,per violalior jorad m `istrative penalties up to$5,000 per viola per day as des c in_p lic Resources Code section 42962. / <br /> Driv -Name rin .D ive s Si niture Date <br /> S <br /> (optioriaYl,:-Addr'ess —1) <br /> Bu iness Name Facility's Business Phone (include area code) <br /> A/ PEI <br /> C <br /> Number&Street Address <br /> I <br /> / '� S ❑Address Same As Hauler <br /> f� I ir-,U �I la Y-, V J 1 I I I I I I I I I I I I I I I ❑ Change Of Address <br /> City r Sfate Zip Code <br /> Tire Types and Amounts Intended Use <br /> l M-2 -7 - fi� J ❑ Passenger ❑ Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix ,m ,m ❑ Recycle <br /> _ [R Truck ❑ Other <br /> El Fuel <br /> hole Tire Count fight in rounds <br /> ,plume Cubic Yards` tgftt in Ton 'm ❑ Disposal/Landfill <br /> oadr�mount <br /> Comfneit ea <br /> ❑Confidentiality Claim: The information provided in Part I 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 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 1-866-896-0600 / WWW.ciWMb.ca.gov/T1res/ <br />