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CA Uniform W to and Used Tire Manife* CaliforniaCatifo integrated Waste Management Board i PO Box 1259, Sacramento,CA 95812-1259 E x A M P L E 2 3 Manifest Number State CrWM of 47(03/0 INSTRUCTIONS ON BACK M4 - 1665496 CIWMB-647(03/t13) , P�RT 1: TO BE COMPLETED BY TIRE HAULER (please print) [Fick Up i ❑ Import from ✓�--�"`� �' (If outside California State/Country) 5• �l f°VC� /�e G livery d G' �t Gam, C/sa Ye ❑ Export to I (If outside California State/Country) Haulers Business Phone 1 (include area code) ( a 7- ) L3 1 �{ _ ) / / / Hauler Exemption (if applicable) I l l L ✓ L O / D `� p), I ❑Government ❑ LEA Exempt Load Date (MM/DDNY) Log Number f ❑Agriculture [J common Carrier/ Back Haul S 40 L/ 7 Q DJ Indicate(if applicable) ❑ In Transit License Plate Number ({ State 1 Decal Number ❑Confidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret.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 contact me at the address and telephone number above. I certify that under penalty of perjury under the laws of the Stale of California that the Information provided above Is true and coned. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler R istration pursuant to Public Resources Code section 42960 and may result in civil penalties p to$25,000 per day,per violation or administrative penalties up to$5,000 per violatio per day as describe blit Resources Code section 42962. G �o Driver'iEIVime(print) D 's i nature Date PART 11: TO BE COMPLE ED BY REPRESENTATIVE C DEALER OR AS IRE GENERATOR OR END-USE FACILITY(please print)- USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. =4X 3 3 3 r � 1( 1Y � i Business N e U ?acllty's Business Phone (include area code) l mlO& 06 e— r � Af' � Ltir Street Address Address Same As Hauler Ls ❑Change Of Address City tate ip Code Tire Types and Amounts Intended Use - - -Passenger ❑Oversize ❑ Retread/Reuse Tire Program ID Site Suffix M ❑ Recycle 14 Load Type(check only one) c ❑Truck ❑Other Fuel ,..Whole Tire Count ❑Weight in Pounds c ❑ Volume Cubic Yards ❑Weight in Tons 10 ❑ DisposaVLandfill CL Load Amount / i O Comment Area ❑Confidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. 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 contact me at the address and telephone number above. I certify that under penalty of perjury under the laws of the State of California that the into ation provided above is tru nd correct.in addition,I am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administr five penalties up to$5, r v lation per day as described in Public Resources Code 4Repre . 1 tive Name(print) Rep nt 's Slgnat ate 32876 ■ Toll Free 1-866-896-0600 / WWW.CiWMb.ca.gov/Tires/ O White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy r�