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••••• CA Uniform Wa and Used Tire ManifesALaliforniaIntegrated Waste Management Board PO Box 1259, Sacramento,CA 95812-1259 EXAMPLE1 l e- 3 A Manifest Number CState IWM -647(03/3 INSTRUCTIONS ON BACK M 1 ` 13 18-9- 2 8 C�IW FAR (03/03) PART . . �:-, P .. Pick U - Hauler (optional-Address Label) P . Business Name Import from' I L� )Y � •.T�� S (If outside California State/Count Address •.Delive City, State, Zip Yat / ' Export to (If outside California Sta+eYCountry Hauler's Business Phone „K41 (include aria code) Hauler Exemption (if applicable) j L ❑Government ❑ LEA Exempt Load Date (MM/DDNY) Log Number ❑Agriculture Common Carrier/ / ( — Back Haul Lt Indicate(if applicable)❑ In Transit m License Plate Number State Decal Number ❑Confidentiality Claim: The information provided i i Part l 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. I certify that under penalty of perjury under the laws of the State of Califomia that the information provided above is true and cor ct. In addition,I am aware that falsification of this information ay result in suspension,revocation,or enia/o,)r newal of the Waste Tire Hauler gistration pursuant:to Pub}l, ourcesCode section 42960 and may result in civil penalties up $25,000 per day,per violation pr ad inistrpenalties up to$5,000 per violn per day as d� bed in Fiiblic Resources Code section 42962. Driver ame(print)/ iv s Si riature Date optional.:�ddress Lae Business Name �� Facility's Businesq,Phone (include area code) N tuber&Street Ad d ess E]Address Same As Hauler (\ l I I I I f ❑Change Of Address City State Zip Code Tire Types and Amounts Intended Use ❑ Passenger ❑Oversize ( f ❑ Retread/Reuse Tire Program ID Site Suffix ,m •m [I Recycle ba.d.T ❑Truck ❑ Other El Fuel 'm ❑Disposal/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. 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 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. I Representative Name(print) Representative's Signature Date 32876 Toll Free 1-866-896-0600 / WWW.ciWMb.ca.gov/Tires/ White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy