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CA Uniform Waftp and Used Tire ManifeE 1alifomiaIntegrated Waste Management Board <br /> PO Box 1259, Sacramento,CA 95812-1259 <br /> EXAMPLE 1 3 � Manifest Number <br /> CIWME-647(03/State of 3) INSTRUCTIONS ON BACK M 8 - 1 3 1 8 9 3 4 <br /> CIWM&647(03/03) <br /> �� Hauler optional-Address Label) <br /> Business Name <br /> Import-fr;7; <br /> m -,r c ['c�, ✓ <br /> ornia State/Country) AddressDelivery City, State, Zipexport to I r* >~ � Cornla State7Countr�t Hauler's Business Phone J i — . <br /> (include area code) 1 ---71..� <br /> Hauler Exemption (if applicable) <br /> z <br /> > ❑ Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> ❑Agriculture El—Common Carrier/ <br /> Back Haul <br /> c 1. C? �� � Indicate(if applicable)❑Jn 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 requestfhat 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 California that the information pr vtded above is ' e an rrect. In addition,I am aware that falsification of this <br /> information may result in suspension,re ocation,or denial of renewal of the Waste Tire Hauler R istration p rs nt to lic Resources Code section 42960 and may result in civil <br /> penalties�4 p to$25,000 per day,per vio tion or dministrative penalties up to$5,000 pyviolatn per day aped crib in Public Resources Code section 42962. <br /> Driver's Name Tint riv 's Signature Date <br /> �4 <br /> Add S- <br /> (optionL"a <br /> en s <br /> Busi s Name Facility's Business Phone (include area code) <br /> 1 <br /> Ntuber&Street Address <br /> I ❑Address Same As Hauler <br /> C) It t I I I I I I ❑Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> ❑ Passenger ❑Oversize .1. � <br /> ❑ Retread/Reuse <br /> Tire Program ID Site Suffix TTI.m m <br /> ❑ Recycle <br /> pe.,check only one) _ ❑Truck ❑Other <br /> eight In Pounds , El Fuel <br /> ❑Disposal/Landfill . <br /> CQrrtnt Ar # <br /> 7�� A <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 SignatAre Date 32876 <br /> ® Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ <br /> White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy <br />