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1 <br /> California Integrated Waste Management Board <br /> ■ CA Uniform Waste and Used Tire Manifest PO Box 1259, Sacramento,CA 95812-1259 ■ <br /> E X A M P L E 112 3 t Manifest Number <br /> State of CaliforniaINSTRUCTIONS ON BACK M G - 1 2 0 3 7 7 5 <br /> CIWMB-647(03/03) <br /> PART 1: TO BE COMPLETED BY TI <br /> I <br /> Hauler �j <br /> �� �� (aptranal-Address Label) II <br /> ❑ Import from Business Name t;t,)t���� tAJ�-� — <br /> (If outside California St a Address 7) <br /> ❑DeliveryGit State, Zi&, y p L <br /> � <br /> = <br /> ❑Export to _ <br /> (f Hauler's Business Phone <br /> (include area code) ( Q ef <br /> pr 2-11 / I �^1 � H:� <br /> Hauler Exemption (if applicable) <br /> �_J El Government El LEA Exempt <br /> Load Date (MM/DDNY) Log Number <br /> El Agriculture El Common Carrier/ <br /> Back Haul <br /> 7= J� L 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 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 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 aay as described in Public Resources Code section 42962. <br /> Lk 1 <br /> Driver's Name(print) Driver's Signature Date <br /> PART III: TO BE C6ffF'E:E'`Ib6'6Y' I=CI S1=1 tATIVIf "h* i -- `AlliFACILITY(please print)-USE ACTUAL LOCATION WHERJ <br /> �A \ti <br /> Business Name Facility's Business Phone(include area code) <br /> L_.._..__._,'_ I I 1 I I I I I I I I I I I <br /> Number&Street Address <br /> l� _ / ❑Address Same As Hauler <br /> I -"I 1 1 ��I -t^��t 1 1 1 1 1 1 I I a_L,1_�I I r._J I rd I C>I t I I E]Change Of Address <br /> City State Zip Code _ <br /> Tire Types and Amounts Intended Use <br /> ❑Passenger El Oversize ElRetread/Reuse <br /> m �m <br /> Tire Program ID Site Suffix ❑Recycle <br /> (Truck ❑Other ❑ Fuel <br /> J �u-ELI I I I I i-ELI ❑Disposal/Landfill <br /> Comment Area <br /> []Confidentiality CI8im: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/Tires/ ■ <br /> White:CIWMB Copy Pink.Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy <br /> FORM NO.M-104799-CIWMB M12 ism 222 98765432 <br />