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California Integrated Waste Management Board <br /> ® CA Uniform Waste and Used Tire Manifest PO Box 1259, Sacramento,CA 95812-1259 ■ <br /> EXAMPLE 2 3 Manifest Number <br /> State CIWM -647(03103) INSTRUCTIONS ON BACK '- '" M 1 ' ..I -2 .8 - I A 3. <br /> CIWMB-647(03/03) ,. . .. ._",�. <br /> 'r0'BE COIUIPLETED <br /> sd(optional-Adre1 <br /> ❑ PHauler Ick;Up I .�.W'6'TRiJCR <br /> ❑.Im ort fromF Business Name 250()l~ <br /> p <br /> (If outside California State%Country Address Past3d>n:. <br /> f ' `- <br /> Delivery City,.State, Zip -- � �� <br /> t CJEzportto <br /> Ly �1 <br /> Haul Business Phone L�LJ <br /> (If outside,GItforrna State/Country' _ <br /> '- ,-'• t-- <br /> (include area code) <br /> Hauler Exemption (if applicable) <br /> ❑Government El LEA Exempt <br /> Load Date (MM/DD/YY) _ Log Number <br /> ❑Agriculture n Common Carrier/ <br /> Back Haul <br /> IfldiCate(if applicable)❑ In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidentiality Claim: The information provided in Part i-a9d Part II of this form should be considered confidential,proprietary,and/or trade secret. It <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 lawsof 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,ddenial 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 Resc-�rces Code section 42962. <br /> Driver's Name(print) DriVer's Signature Date <br /> LfF,AClLIT <br /> ART II TO BE COMPLETED BY REPRESENTATIV O�RE DEALER OR WASTE TIkE.`bEhERATOR OR END-USE ' <br /> Y( lease rint .-USE ACTUAL LOCATION WHERE THE TIRES ARE.PICKED,-UP.ORDROPPED OFF;. <br /> (optional-Address Label) <br /> � 1 -71 <br /> � � 1 ) 1 <br /> Business Name Facility's Business Phone (include area code) <br /> _- <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> ❑Change Of Address <br /> City State Zip Code <br /> -m Tire Types and Amounts Intended Use <br /> ❑ Passenger ❑Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix •m m <br /> ❑ Recycle <br /> oad Type(check only one) ❑Truck ❑Other <br /> hole Tire Count Weight m Pounds N El Fuel <br /> O <br /> olumeACubtc Yards ❑ eight inJ <br /> l <br /> ❑Disposal/Landfill <br /> �., Comment Area <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 S5,000 per violation per day as described;n 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 Ccpy <br />