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.ISG}':4;�?`i�'..'�+�'M-it'e�.':*'r,��L. „�•',.,+!LL�, �..• ..ti . ::�.--.r.- .:moi. .�:�?...... . _� ..tAA�'i", gjyi,`>s'JI''M• v. t,3.Nhir: r.,...-,,.,,..'ki>°..`�, � ::r � I'll Inttgreli Waste UWagamem Board ■ a CA Uniform Waste and Used Tire Mailiftst PO BOK 1259, Sacramento.CA 96912.1259 EXAMPLE 1 2 3 Manifest Number M9 , 1241 � 96 CIWU,647(0510#) INSTRUCTIONS ON B/lCK PART-1 : TO K- CO�li11P.LSTBD'b* tiRt'bAI'L9R:0,4Mpip Iqp ._ ❑ Pick Up I_. ... ❑ Import from I (If outside CaMorrila Stale/Country) a ^C�W�� i`�✓� ;❑ Delivery ❑Export to Business Phone (It outside Galltarnla$tale/Country) ( C U de area code) ) 1 / 4 L / Hauler Exemption (if applicable)v L] GovernmAM [2 LEA Exempt Load Dfate(Mfvt/oo/yv) Log Number C1 AgdCuRVID ❑Common Carrier/ . 1 Back Haul Indicate(If applicable)❑In Transit License Plate Number State Decal umber OContidentlallty Claim: The Information provided In Part I and Part 11 of this form should be Considered ronfidanllal, proprietary,and/or trade secret. In accordance with Title 14,CCR, Section 17041 el.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 oaAlfy that ucder penalty of perjury under the laws of the Stale of Calffomla Thal rhe InfOrmatlon provided above is True and ootradi In addition,I am aware that fa..slHcimon of this Information may result In su9pensian,revccallon,or denial of renewal of the Waste Tlra Haler Registration pursuant to Ptlbllc Resources Code section 42860 and may resuit in civil penalties up to$25,D00 per day,per violation or admin strative penalties up to$6, per day as described in Publlo Resources Code aedion 42062. Driver's Name(print) Ivorr'e 1 nature - - 1&&A PAi p: TO BT MPI)` L 1f;F 'II tr41' b a.J r r "111411, y /yam .. FACILITY t leaas.pdnt) USE_A iiiI �{. �A#'KIM,WI,�� sTFf Sualness7Nbm Facility's ualneaa Phone (tnclud9 area node) Number A Street Address ❑Addraea Same As Haulor ❑Change OfAddress city Zip$tames zip Code Tire Types and Amounts Intended Use . ` , b O ❑ Passenger ❑Oversize read/Reuse T re rogram I D Vie Su ix G Recycle Lo yps(check Orly one .. amuck ❑Other i hol6 Tire Count El Weight 1n Pounds a D Fuel Volumq Cubic Yards [3 Weight in Tone ` ❑DisposaULandflll Load Amount Q Comment Area ❑Confldentlaiity Claim: The Information orovlded In Pan I and Part II of this form should be Considered confidential,proprietary,And'or I'ade secret, In accordance with Title 14,CCR,Section 17041 at.il should any member of the public request disclosure of this Information, I request that C+WMB contact me et the address and telephone number above. I certify that urufer penalty of palury,,rider the laws of the Slate of California tftat the Information provided above Is true and Correa.In addllivn,I am aware that tale fcatlon d this Inbrmailon may rmlt In civil penalties up to$25,000 par day,per dolawn or administrative penalties up to s5,000 per pa day a6 desatb*d In Publlo Resources Code asetfon 4291 t r. �yez(gC; ,. 12j4l Representative hams(print) Re "ental. e's Signature Date 32876 Toll Free 1.866-896-0600 / www.clwmb-ca.gov/Tlres/ E -d 0666 13CN3SH-1 dH WdOZ :ZT 9002 LO UeC