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s ' A Uniform Waste and Used Tire) Manifest California Integrated Waste Management Board ■ PO Box 1259, Sacramento,CA 95812-1259 E X A M P L E Tl� Manifest Number tou �t.40-sa�(fWrlrarrlman�� INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICA 1 c M3 - 2051175 . ts By signing this CA uniform Waste and Used Tire Manifest,the signer(s)requests that the information provided on this form will be considered confidential,proprietary and/or a trade secret. In accordance with Title 14,CCR,Section 17041 at seq.,if a request is made for disclosure of this information,the CIWMB wiU contact the signers)of this form at the address and telephone number provided on this manifest. PART I: TO BE COMPLETED BY TIRE HAULER PLEASE PRINT FIRMLY ti r �-- \pick lJp Deilver Please complete if outside California L7 import/Export Hauler's Business Phone State/Country (include area code) r ' 3 - Ll q Z� Load Date (MM/DD/YY) Log Number G� Hauler Exemption(if atpplicable) ! o5- � / b L � g ❑Government ❑ LEA Exempt / ! ❑Agriculture ❑Common Carrier/ License Plate Number State Decal Number Back Haul Indicate (if applicable) ❑ In Transit ❑Unregistered Hauler I certity that under penalty of perjury under the laws of the State of California that the informat:onpr above is true and correct. In addition.I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Haul Mg, ration pursuant to Public Resources Code section 42960 and may result ,civil penalties up to$25,000 per day per violation or administrative penalties up to$5,000 per latio r day as des alba in Public Resources Code section 42982. river's game(print) �riversature ate PART It: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. USE ACTUAL LOCATION WHERE THE"TIRES ARE PICKED-UP OR DROPPED OFF. PLEASE PRINT FIRMLY Business Name Facility's Business Phone (inrlucle area code) Num er& Street Address -city State Zip Code Address Same As Hauler — fit c �/ � � __-w) 2 E]Change Of Address Tire Program ID Site Suffix Load Type (heck only one) [ Load Amount f V_�Wttole Tire Count �Weight in Pounds �� c� ■ tf Volume Cubic Yards Weight in Tons Whole Numbers only Decimal for Whole Tire Count .� Passenger Amount Oversize Amount Intended Use to ❑ Retread/Reuse Recycle ❑Fuel ❑Disposal/Landfill O C2-' [ ■ ■ Comment Area Truck Amount Other Amount ® ■ ■ 1 certify that under penalty of perjury under the laws of the State of California that the information provided above s true and correct.In addition,I am aware that faisificakon of this inlonriatioin 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 section 42962. KM _CX AA� C ----- Representative Name(print) Repres tative s Signature Date 26 187 ® Toll Free 1-866-896-0600 1 www.Ciwmb.ca.gov/Tires/ White:CIWMB Copy Pink:Tire Dealer/GeneratorlEnd-Usa Facility Copy Yellow:Haver Copy s . ® 1.Remove top stub 2. Fold In half at fold line 3. Remove adhesive strip 4.. Adhere remaining stub M12 «?« 51416766431 FORM NO.M-1o4799•GwMi3 DO NOT REMOVE THIS STUB