Laserfiche WebLink
E kA M P ILIE I 119 <br /> stat OMof 8-64iifornia MS�TR`UCTIONS ©N BACs. <br /> 1WMB 6�:7(031091 , <br /> PART L TO,BE COMPLETED BY TIRE HAULER (please,print) <br /> RckUp �j a <br /> t Bu • } '. <br /> ❑Importfrorw; <br /> (If outside Cabfornia State(Country) adres z r ,"* � <br /> ®slivery r"ity, Stale, 7i <br /> C] Export to <br /> y)( <br /> If outside Hauler's Business Phone <br /> Californ'la StatelGountr <br /> _ hnclude area code) <br /> mauler Exemption (if applicable) <br /> ❑ Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number ❑ Agriculture ❑ Common Carrier/ <br /> Back Haul <br /> I / �_g r ', �S ,I { ; I v :� �, + Indicate(if applicable) [IIn Transit <br /> _ a <br /> ti <br /> []Confidentiality Claim. The infonnaton p ovided ,n art Iand Pn t ;l of this form should be considered confideniial I.,ropr1euest that/CIWMB contact <br /> accordance with Title 14, CCR; Section 17041 et.seq,should any member of the public request disclosure of this Information, I eq <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 c'.vil <br /> penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation irar day as described in Public Resources Code section 42962. <br /> _ — - <br /> river`s lvaaxte givers Signature <br /> Date <br /> _rive ll: T4 13 DC 11 f�LM D° r 1T�A�t of�"f'MECid-AL.I;WOII WASTE'1`IRL GENERATOR OR END-USE <br /> y. r i e rint)- USE AOTUAL.LOC.ATIQN VI/HERE THIE TIRES ARE PICKED UP OR DROPPED OFF. ; <br /> 6 I <br /> 1 <br /> f <br /> Facility's Business Phone (inCltide area code) <br /> Business Name n, <br /> V Y K J2 <br /> 'umber&Street Address <br /> ` j <br /> F1 Address Sarre As Hauler <br /> s „ <br /> ❑Change Of Address <br /> O Stat I I 1 { <br /> L.._ -i ' <br /> State Zip Code <br /> --- �1­1 _ Intended Use <br /> - Tire Types and Amounts <br /> i <br /> [I Passenger <br /> ❑Oversize ❑ Retread/Reuse <br /> Tire Pro r I .IDI Site Suffix I r I � � iJ Recycle <br /> 1 � - - <br /> Tr�u�k <br /> E]Other ❑ Fuel <br /> Cfa y c er a Yon , C7 I ._ <br /> Whole I Ire Couflt �-]Weight In Pounds � 7__1 � � I <br /> I ❑ Disposal/Landfill <br /> Volume Yards tWeight In Tons ! I•L.- Iii ' L--_.L J _-J 1 <br /> - - -- - — - <br /> x�e, <br /> o.ad Amount Comment Area <br /> [1COrlfldentlahty Claim," The information provided in P I nd 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,s,lr6uld any member of the public request disclosure of this information, I request that CIWMB <br /> contact me at the address and telephone number ab�. <br /> ?: nd correc <br /> I certify that under penalty of perjury under the laws the State of v olation orad California thathnistrat ve information <br /> penalt esdup to$5 OOOed above is tper rue vio ation per day asltdescr bed n PublictResources Code Is <br /> information may result in civil penalties up to er da per t <br /> section 42962. jh �4A z xis ,a s � '`z •. � f+�v� y .R- <br /> Represeptative Name (print) <br /> Representative's Signature Date 32876 <br /> Toll Free 1-866-896-0600 / www.ciwmb.ca,gov/Tires/ <br /> NIrAL Copy Pink:Tire Dealer/Generator =nc! -Use Facility Copy Yeliovv:Hauler Copy <br /> #, � 4 aPgwnrl3, 4-pef" r * s <br /> FORM NO M-104799 CIWMa•M12 icrxi 2 � �:� <br />