Laserfiche WebLink
_ �CA Uniform Waste and Used Tire Manifest CaliforniairltegratedW�teManagement Board <br /> PO Box 1259, Sacramento,CA 95812-19 ■ <br /> E X A M P L E 1 2 3 Manifest Number <br /> State of California• p�---- - <br /> CIWMB-647(03/03) INSTRUCTIONS ON BACK IYI 6 • Z Q 3- 7 <br /> Hauler (option -Address Label) <br /> Business Name CU* r T t r"Q.- <br /> Address <br /> i City, State,Zip ' �C—k-:t --'t t, <br /> Hauler's Business Phone <br /> (include area code) ( �� / — ^� p <br /> _ Lai a+- <br /> Isd I <br /> �L _ Hauler Exemption (if applicable) <br /> Load Date(MM/DD/YY) Lo Number ❑Government❑LEA Exempt <br /> -- - g i <br /> ❑Agriculture ❑Common Carrier/ <br /> Back Haul <br /> License Plate Number LIndicate(if applicable)p In Transit <br /> State _ Decal Number <br /> Confidentiality Claim:The information provided in Part I and Part II of this forho 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 6quest 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$25x000 per day,per violation or administrative penalties up to$5,000 per violation er day as described in Public Resources Code section 42962. J <br /> Y'S <br /> Driver's Nameprint) , <br /> Drivers Signature Date <br /> PAItT ii: T` '§V V ESEN'I'AT t <br /> FACILITY(ple : � -USE ACTUAL.LOCATION W <br /> 1-abet <br /> OiVl <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> I JI Q I I I I I I I ��. , tCj, 1 ' I I s` ! <br /> City , , l]Change Of Address <br /> State ZIP Code <br /> /�, �� Tire Types and Amounts <br /> C.,.f S `7 �� -}. -` I ( I ❑Passenger ❑Oversize Intended Use <br /> Tire Program ID Site Suffix .m Retread/Reuse <br /> ❑Recycle <br /> Truck ❑Other <br /> • � �.� ❑Fuel <br /> 'm •m <br /> Disposal/Landfill <br /> Comment Area <br /> oconfidentiality 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 /> mea /Z <br /> Representative Name(print) Representative's Signature <br /> 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•-plt2-ow-M,981! .--- <br />