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California Integrated Waste Management Board <br /> CA Uniform Waste and Used Tire Manifes PO Box 1259, Sacramento,CA 95612-1259 <br /> w <br /> EXAMPLE <br /> 2 3 C Manifest Number <br /> iu <br /> stele a California INSTRUCTIONS ON BACK 111 3 - 16 5 12 2 " <br /> CIWMB-647(03X3) . <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> 17 Pick Up <br /> ❑ Import from I` 1 ✓�` <br /> (If outside California State/Country) <br /> ❑ Delivery <br /> ❑ Export to <br /> IS outside California State/Count Hauler' Business Phone <br /> ( ry) i (include area code) © � ) � � <br /> � � O _ � D Hauler Exemption (if applicable) <br /> Jf lli ❑Government ❑LEA Exempt <br /> Load Date (MM/DDNY) Log Number <br /> ❑ Agriculture El Common Carrier/ <br /> G /6— c-) <br /> - O Back Haul <br /> Indicate(ii applicable)❑ In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidentiality Claim: The information provided in Part I and Part 11 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 /> I certify that under penalty of perjury under the laws of the State of Califomia that the information provided above i 4r7 and correct. In addition,I em aware that falsification of this <br /> information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration u 96 <br /> to Public Resources Code section 420 and may result in dull <br /> Q allies up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per is of ribed In Public esources Code section 42962. <br /> 1� Iy /- � <br /> Driver's Name(print) Driv gnat a Date <br /> PART II: TO BE COMPLETE BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE <br /> FACILITY(please print) -USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. <br /> M1c6it-.,5 047 ) 2 6 9 - -5 <br /> Business Name Facility's Business Phone (include area code) <br /> .3 ;4 �1� E_- KMAN- A <br /> Number& Street Address <br /> ❑Address Same As Hauler <br /> ❑Change Of Address <br /> City Slllt...aate Zip Code <br /> Tire Types and Amounts Intended Use <br /> ❑ Passenger ❑Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix M <br /> 0. ❑ Recycle <br /> M <br /> Load Type(check only one) ❑Truck ❑Other <br /> F-1WholeTire Count ❑Weight in Pounds c E] Fuel <br /> Votume Cubic Yards ❑Weight in Tons <br /> ❑ Disposal/Landfill <br /> CL <br /> Load Amount i 0 Comment Area <br /> ❑ConfidentialityCCllaim: 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 /> 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 penaRies to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. <br /> Representativ Name(print) Represe ative's Signature ElIi6te 32876 <br /> ■ Toll Free 1-866-896-0600 / WWW.dWMb.ca.govlTires/ <br /> White:CIWMB Copy Pink:Tire Dealer/Generator/Encl-Use Faalily Copy Yellow:Hauier Copy <br />