Laserfiche WebLink
and Used Tire Manif California Integrated Waste Management Board <br /> PO Box 1259, Sacramento,CA 95812-1259 <br /> i�I t Y I -13 I -C Manifest Number <br /> I State of 8-647(ornla 1 5 . 1 3 1 8 <br /> CIWMB-647(03/03) INSTRUCTIONS ON BACK Z <br /> O� BE Mp`ED BY TIRE H' <br /> Pick U :Hauler — <br /> P I(optional-Address Labeo <br /> Itport from Business 1me -�'"' <br /> ! ; <br /> {If outside c2lito3 to i Address <br /> LIPIver <br /> 4 Y City, State, Zip <br /> Aorr_ _ <br /> Hauler's Business a S s Phone <br /> (include-area code) <br /> Hauler Exemption (if applicable) <br /> Load Date (MM/DDNY) Log Number ❑ Government [:1 LEA Exempt <br /> w - ❑Agriculture ❑Common Carrier/ <br /> Back Haul <br /> Indicate(if applicable)❑ In Transit <br /> License Plate Number - State Decal Number <br /> ❑Confidentiality Claim: The information provided in Part I and Part I('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 informlation, 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 informatioh provided above is trhe and correct. In addition,I am aware that falsification of this <br /> information,may result in suspension,revocation,or denial of renewal of the Waste Tire Haub Registration pursua t to Public Resources Code section 42960 and may result in civil <br /> penalties up to$25,000 per day,per violation r administrative penalties up to$5,000 perYlolstion per day as descr bed in Public Resource Code section 42962. <br /> \� <br /> Driver's Name <br /> print) D ivey s Si nature­ Date <br /> 66 E3Y F FP <br /> ITAClLI P�a,e r r lJ E. E' ' R OR END USI <br /> a <br /> �.__ <br /> (optional-=�dreQU <br /> ss�'ba r,.:.s_�r----� -�- � <br /> CID CSI <br /> Business `ame Facility's Business;Phone (include area code) <br /> Number&Street Address i <br /> - f ❑Address Same As Hauler <br /> t i r <br /> I I I I t I I `. 11 P I I I I I I 1 I I L �_.I '' I I I I ❑Change Of Address <br /> City State Zip Code <br /> _ Tire Types c-ld Amounts Intended Use <br /> �f _ , <br /> (w T - ( ❑ Passenger ❑Oversize <br /> Tire Pro ram ID ❑Retread/Reuse <br /> 9 Site Suffix •m <br /> '' ¢ •m ❑Recycle <br /> bad Type(check onl one) f Truck <br /> Whole Tire Count' Weight I Poun El Other ❑ Fuel <br /> Volu e Cubic Yatds Weigh', In Tons' .1m <br /> OaCi (]Disposal/Landfill <br /> Comment Arta <br /> ❑Confidentiality Claim: The information provided in Part I and Part 11bf 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 info-r kation 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 /> , i <br /> Representative Name(print) Representative's Signature® Date <br /> Tolf ,�'ree 1-866-896-0600/ iivww.ciwmb.ca.gov/Tires/ 32876 <br /> � <br /> White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy ;' <br />