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California Integrated Waste Management board <br /> CA Uniform W to and Used Tire Manife� PO Box 1259, Sacramento,CA 95812-1259 <br /> W EXAMPLE 3 Manifest Number <br /> State of CRING nil M6 - 1005457 <br /> crwMB-647(01103) INSTRUCTIONS ON BACK <br /> PART L• TO BE COMPLETED BY TIRE HAULER(please print) <br /> �JkU 11 <br /> om -1 <br /> (IfoutsideCalifomiaState/Country) qoo 5CL C9 <br /> Delivery �0CU t c4i C Cl d' <br /> ❑ Export to <br /> (IfoutsideCalifoniaState/Country) HaulersBusiness Phone <br /> (include area ode) , r , <br /> f—tl <br /> D / o- I 0 T _ Hauler Exemption(if applicable) <br /> L ❑Government❑AmnestyDay <br /> Load Date Log Number ❑Agriculture ❑CommonCarrler/ <br /> 5 L C O 275 <br /> _ Back Haul <br /> rJl IndlCate (if applicable)❑ InTranslt <br /> License Plate Number State Decal Number <br /> ❑Confidentiality Claim:The information provided in Part I and Part II of this form 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 request disclosure of this information, I request that CIWMB contact <br /> me at the address and telephone number above. <br /> 1 cortify 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 falsRcabon 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 /> pen I s up to$25,000000 per violation or administrative penalties up to$5,OW per violation per day as desai Public Resources Code section 42962. <br /> o I I , -d �3, <br /> Driver Name(print)_ D is gna Date <br /> PAR I: TO BE COMPLET BY REPRESENTATIVE OF TIRE DEALER OR Wila TIRE GENERATOR OR END-USE <br /> FACILITY(please print)-USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. <br /> i f' ve. 909 3 33 W`/ y �, <br /> Busi ess Name Facility's Business Phone(include area code) <br /> ll� 0 5• C14 j- o KEF <br /> Number& Street Address <br /> ❑Address Same As Hauler <br /> Q t C # L7 5 E]Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> 1 ❑ Passenger ❑Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix ❑ Recycle <br /> ro <br /> Load Type(check only one) j ❑Truck ❑Other ❑ Fuel <br /> ❑Whole Tire Count Weight in Pounds I C <br /> Volume Cubic Yards Weight in Tons 2 ❑ Disposal/Landfill <br /> a <br /> Load Amount U a O Comment Area <br /> 1 L <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 penally of perjury under the taws of the State of California that the information provided a ve 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 o 000 per an <br /> per day as described in Public Resources Code <br /> section 42962. <br /> i ✓YQ4t�l <br /> t <br /> Represe&ative Name(prin Rep es ative's S at r Date 55939 <br />