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CA Uniform Wa s_f avid Used Tire Trip L o j ,ali O Bo Integrated Waste Management-1259 <br /> •••• M PO Box ,259, Sacrarraento,C'A 95811-1259 <br /> 1 'r <br /> EXAM;PI. E T123 9 <br /> I ��_J �- o Number <br /> CState lwM -648(0rua INSTRUCTIONS ON BACK L 8 13 2 8 8 4 2 <br /> CIw 1Yl8.646(U3l03) <br /> 0S~ j d � 0S" � a <br /> Master Log Number Decal Number Initial Trip Date (mm/OD/YY) <br /> —_ <br /> S Hauler's Business Phone (include area code) <br /> _ L r �`" t_ ❑Confidentiality Claim:The information provided on this form should be <br /> considered confidential,proprietary and/or a trade secret. In accordance <br /> with Title 14,CCR,Section 17041 st.seq, should any member of the publ;c <br /> �,• /t request disclosure of this information. I request that CIW MB contact me at <br /> ❑ Change Of Address �� "� the address and telephone number fisted in this section. <br /> Manifest Number �-� load R;G� Load Amount <br /> -^Pldctap hole ❑ Weight (Lbs.) <br /> . may .. Dslivery, [] Volume(Cu.Yds.) ❑ Weight (Tons) <br /> r <br /> - <br /> Pick uQ Ci Whole Tire (Count) ❑ lNeight (Lbs.) <br /> Delivery ❑Volume(Cu.Yds.) ]Weight (Tons) <br /> M - <br /> �kup ❑WholeTire (Count) ❑Weight (Lbs.) <br /> ❑Volume(Cu.Yds.) ❑Weight (Tons) <br /> M Pickup ❑Whole Tire (Count) ❑Weight (Lbs.) <br /> IY! Delivery ❑ Volume(Cu.Yds.) ❑Weight (Tons) <br /> M - Pickup C1 Whole Tire (Count) ❑Weight (Lbs.) <br /> Delivery ❑ Volume(Cu.Yds.) ❑ Weight (Tons) <br /> - Pickup ❑Whole Tire (Count) E]Weight (Lbs..) <br /> Delivery ❑Volume(Cu.Yds.) ElWeight (Tons) <br /> t <br /> M - Pickup ❑Whole Tire (Count) ❑Weight (Lbs.) <br /> Delivery ❑Volume(Cu.Yds.) ❑Weight (Tons) <br /> - Pickup ❑Whole Tire (Count) ❑Weight (Lbs.) <br /> Delivery []Volume(Cu.Yds.) ❑Weight (Tans) <br /> h - Pickup ❑Whole Tire (Count) ❑ Weight (Lbs.) <br /> IVI Delivery ❑Volume(Cu.Yds.) ❑Weight (Tons) <br /> N A - Pickup ❑Whole Tire (Count) ❑Weight (Lbs.) <br /> iVt Delivery ❑Volume(Cu.Yds.) ❑Weight (Tons) <br /> certity unde,penalty of perjury under the laws of the State of California that the information provided above is Please indicate if applicable: ❑ Load in transit <br /> +rue and correct. In tiddi:ion,I arr aware That falsJhcarion of this irdorma.tion may result in suspems,on,revocation,or denial of renewal of the <br /> Vdaste Trre Hauler Registration pursuant w Public Resources Code section 42960 and may result rr cwil a i up to$25,000 per day,per Page of <br /> violation or administrative penalties uo to$5.000 per violation per day as described in Public Resour s Code s tbn 4 82. <br /> Driver's Name (print') Driver's Siia6W7 Date <br /> Toll Free 1-866-£196-0600 / wWW.oiWrnb.Ca.gov/Tires/ <br /> White:CIWMBCcTy Yel'ow:Hauler Copy <br />