Laserfiche WebLink
Ii <br /> =SE'" <br /> reE XA M P ' L E l 3Manifest V. <br /> r; iber <br /> V <br /> State of California - -- <br /> Clwnie-ca>(oslas) INSTRUCTIONS !civ BAC M <br /> 0414 LER:(please,print) <br /> l'C� BE.CQIIftPI�ETEpr? BY FIRE l'iAl3 <br /> Pick U.p] a�r : 1<<�utf{ tI- to ss Lakcat <br /> �1.i lEi r• Y� <br /> C' Import,from: .� <br /> I <br /> 1 <br /> (If outside Galitorni;A.trifle,/Country) <br /> Delivery City, ,t. , Zip !1� '. <br /> C_ <br /> Export to :r <br /> - Hauler's Business Phone I' <br /> - <br /> allfun ii:� Stat (CounPfy) co <br /> (lf outsu�� (include area code) <br /> Hauler Exemption (if applicable) <br /> ❑ Government ❑ LEA Exempt <br /> Loan' i")a�e MNl °og nl_°mber <br /> 11 - ❑ Agriculture ❑ Common Carrier/ <br /> i 1 j i /j I - r Back Haul <br /> I I � <br /> Indicate(if applicable)❑ In Transit <br /> License Plate NLImber State Decal N, -umb-er,.-- <br /> "Aw , <br /> CJ Confidentiality Claim: The Inronr!atlon provided In Part I and Part II of this form shouldbe considered confidential. proprietary, and/ trade secretin <br /> accordance with Title 14, CCH, 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 California that the information provided above is true and correct. In addition,I am aware that falsification 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 /> penalties dip to$25;000 per day,per vioicition or administrative penalties up to$5,000 per violati9n per day as described in Public Resources Code section 42962. <br /> --— <br /> . river's Na,rrfe Driver's Signature – Cage-- <br /> PART WI. TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE <br /> FAC1L.iTY (pie print) - USE AC TUAI,. LOCATION WHERE THE-TiRES ARE-PICKED-UP OR DROPPED OFF, <br /> Business Name Faciiity's BUSiness Phone (include area code) <br /> } <br /> N <br /> LarT Jc' Street Address <br /> F�, L� <br /> dress - <br /> - ' ll - ❑Address Same As Hauler <br /> ,t_. .L_— __– )--�_--..__ –_-- _-,__ __..-1 E] Change Of Address <br /> City State Zip Code <br /> 4i Tire Types and Amounts Intended Use <br /> I <br /> Passenger g El Oversize I ❑ Retread/Reuse <br /> Tire Program 1­1Site Suffix I I I i ' I I <br /> 1 I II ❑ recycle ,� <br /> Load Type(check only one f J Ti nck E] Other <br /> r� Whole Tire Count Weight in Pounds --!----_ _-�— . _. �_� r ❑ f=uel <br /> Volume Cubic Yards Weight in Tons O I <br /> • - )• __-� -_ + I_ ; I I• � ❑ Disposal,!Landfill <br /> Load Amount ------_---------- <br /> OComment Area <br /> [v�j..Ccnfidentiality Claim: The intormation 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 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 penalties up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. <br /> t` <br /> Representative Name (print) Representative's Signature Date <br /> ,12876 <br /> Toll Free 1-866-896-0600 / WWW.CiWmb.ca:gov/Tires/ <br /> Pink:Tjre Dealer/GeneriturE^d-Use Facility Copy Yellcw Healer Cn, <br /> r <br /> r � <br />