COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

i qw q r' rr „w •r' �s C :;F e R ¢ sr ?C rfl .r uER oev"b.• a y w rara+e+u•w v e , -:.tu.',6�, )'_...L•;P .�:.J::'ri. y�.A'�+.yi.-�15�'irS;o�i�• r{5�.� �'o-y��^�+�4:i�i' ;f�•-.• 'r'`SF :rrrr. Ai7rlt!tis4dF'. rt4rr.$'. �, s 'lsd!Plf `IhalC:� 111 sunt,, t aE� CA Uniform waste and IJmild Tire Manifest Callfomts Irn"rated Waste WnaperrQT Board PO Box 1269. SW smsnto CA 95812-1258 JE-JXJAJMJPJLJEJ 111273 Manifeet Number IIlbee sr CaliferAp n CrM1./4Yse1'cam) INSTRUCTIONS ON BACK ._..-_.... _. 1 . 12 4 7 6 9 1 7 C PART 1, TC1� OMPL"D:81i': ' i r i❑P19k UP ❑Import Iram { outalaa aft mis: tatelrbunt►y) O� ii,,�-%A .� ❑ Export to >iauler'6 Business Phone 1 If outside Cellfotnla �v) Stele/Coun preclude area code) p �._._. .__. . .. Mauler Exemption (t applicable) r ❑Dovemment❑LEA Exempt Lood Date (mwoo>'>'v) Log Number ❑Agriculture ❑Common Ca,risrr f� `��,.w.r Back Haul 2, Cl�1 V �J Indicate(if applicable)❑ In Transit License Plate Number State Diciil Number ❑Confidentlelity CISIm: The Information provided in Part!and Pert II of this form should be considered confidential,proprietary, and/or trade secret. In accordance with Title 14,CCR.Section 17041 el sac,should any member of the public request dlselosire 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 t'aliromie that the Information provided above is true eno correct. In addition,'am aware that%isitcatlon of tni3 nforr"ation may result in suspens.on,revorall on•or deal at of renewal of the waste Tire Hauler Registration pursuant to Pub hC Ae9OUICee Coca seotlor 42980 and may faii in olvii peneitle9 up to$25,000 per clay,per violettor,or adrninislrat"penalties up to ss.o0o per violatl2azer day ea deeCribetl In P lie Rasourae Coda aeetion 42062/ �� �'ul�s /z./) A V Drl�l r7s Na a(�rint Driver's SISnature Date 1,: 'I�t.�:�`#i�P'��',�'I'll .`'�I�` '�I��'Y� .� '��T ,tl 'r`F •if`�IYO�I� FAOILI' f-({a1Pas@. nth=W E 1t4'M 10L L l�A t 1' ift'TFI .'•rlftJE its;PICKED-UPOP Al Business Name Facility's Business Phone(include area code) Number tit Street Address \ ❑Address Same Aa Hauler "1 1 �Q� � ! ❑CraNe Of Address City State Zip Code Tire Types and Amounts Intended Us® LAD ( , 1 ❑Passenger EDoverslso etnead/Reuae Tiro Program 10 Site$u ix . .. _._ ❑Recycle '�jGA¢Ck,i>t ly4nq) 'u°rt ❑mar if +oi4 T►r4tJftttta,gtn in•fAisatde; ❑Fuel 1_h 16 d 6 '.': YValpttt IA'TtSn�;a:,. .` ❑DlsposatA anaflll Loud Xaiount Comment Area ❑Con identlelity Claim: The information provided In Part I and Part fl 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 disclosurs of this informatlon.I request that CIWMB contact me at the 9ddraes and telephone number above. I codly that under penalty of perjury under the laws of the State of Cal lom'a that the Info,metlon provided above Is true and correct.In addition,i am aware that faiailicetion of lhie Information may result,n chit ponaltise up to$25,000 per day,ver vfolsllon or adminislra*1 Penarle9 up to Sti,000.por viaipll day as des,w;bed In%blic Reeourt`se Code sealer 42982. Repreeentetive Name(print) esentat e's Signature Date 32876 ltd TAII barren 1_00C_t'44-inicfln / Z 'd OEEE 1A178ASd-1 dH WdO2 :21 SOOZ LO uer