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CA Uniform Waste and Used Tire Manifest California Integrated Waste Management Board <br /> PO Box 1259, Sacramento,CA 95812-1259 ■ <br /> a EXAMPLE 1 2 3 <br /> Manifest Number pry <br /> State of California I M �1 . 1 J 1 8 9 J 1 <br /> CIWMB-647(03/03) INSTRUCTIONS ON BACK III VVV <br /> Ck Up Hauler (optional-Address Label) <br /> Business Name) T j <br /> Import from <br /> (If outside alifot ate Q3 n1 Address <br /> 8 <br /> el�very City, State, Zip �` 7 <br /> Export to <br /> (If outside Caufornia State Hauler's Business Phone ,t <br /> (include area code) <br /> Hauler Exemption (if applicable) <br /> ❑ Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> ❑AgricultureCommon Carrier/ <br /> Back Haul <br /> -! G ` t ! ? % ` I j / Indicate(if applicable)❑ 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 /> I certify that under penalty of perjury under the laws of the State of California that the information provided above is true acorrect. In addition,I am aware that falsification of this <br /> 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 <br /> 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. <br /> Driver's Name rint Driver's Signature Date <br /> .._ 0 f3QPPE <br /> (optional-Address Label) <br /> MI <br /> Business Name Facility's Business Phone (include area code) <br /> I ' I I i I I I I ! <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> I'��-.I I 1r l 1 1 h; I I I I I I I I I I I T I I I !�I ❑Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> + ❑ Passenger ❑ Oversize <br /> ❑ Retread/Reuse <br /> Tire Program ID Site Suffix <br /> El Recycle <br /> ype(che - ❑Truck ❑Other <br /> Idhf in Pounds ❑ Fuel <br /> ht..i - on { t_ r 'm ❑ Disposal/Landfill <br /> CAmment A 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 Signature Date 32876 <br /> Toll Free 1-866-896-0600 / www.c1wmb.ca.gov/T1res/ I _ <br />