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Rug 13 04 04: 53p @ 2094630199 p. 3 <br /> California Integrated Wastemanagement Board <br /> CA Uniform Waste and Used Tire Manifest p0t3oz124 Sacramento,CA 95812-1259 <br /> ■ ` E X A M'P LEI 1 2 3 - 'Mariifinet Number __ . <br /> State.of California• INSTRUCTIONS ON BACK -' 3 4 062 <br /> CIWfA&647(03/03) <br /> Hauler (optional-Address Labeq <br /> _._ Business Name <br /> Address <br /> 3� a <br /> _ . .. City, State,Zip I •�'�-U��Tlt"_ i�.i'�' C1,5`��17.� <br /> Haul Business Phone r <br /> (include area code) l } Ll <br /> I � <br /> Hauler Exemption <br /> r <br /> ylJ ❑Government❑LEA Exempt <br /> _ rn tion (it applicable) <br /> Load Date(MMIDD/YY) Log Number ❑Agriculture p common Carrierl <br /> Z/ Indicate Back Haut <br /> _I� 1.� 1.1�-!__l l t!Jj' —L'--r 1--1 Indicate(it applicable)❑In transit <br /> License Plate Number State WDecal Num_taer <br /> OConfidentiality Clam: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 17641 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 Caldomia[hat 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 42060 and may result in civil <br /> 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 section 42962. <br /> Driver's Name(print) Driver's Si§nature ------- Date <br /> f= �1L11-4'`k'p eat Cl <br /> {ol5(rorial-Address Label) <br /> Business Name Facility's Business Phone(include area code) <br /> /#>21—Vt ��_ <br /> Nurnhr&Stree--ddress 1�1 <br /> ❑Address Same As Hauler <br /> L.- .. ..-,r E- I�' J'--t._!�J—J__ L—L—�__l�l t 1 L{{._ {;i I L�'�_L "r �L�J ❑Change Of Address <br /> City State2i�ode _ <br /> - Tire Types and Amounts Intended Use <br /> ❑tI <br /> Passenger Q ❑Oversize ❑19etread/Reuse <br /> fire Program ID Site Suffix ` <br /> — I <br /> j.ED ❑Recycle <br /> }T ` (]Truck ❑Other ❑Fuel <br /> gGltfie t 411' ELID ❑Disposaltl-andfill <br /> -oed.�4. � • Comment Area _ - ------•__-�____.._ <br /> Y <br /> I , <br /> , 9 <br /> .""QConfidentiality Claim:The Information provided in Part I and Part 11 of this form should be considered confidential,proprietary,and/or trade secret. <br /> i. to 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 /> Y, contact me at the address and telephone number above. <br /> s I certify that under penally of perl'ury under the laws of the State of California that the information provided above is hue and correct.to addition,I am aware that falsification of this <br /> information may result In civil penalties up t $25,000 per day,per violation or administrative penaeies up to$5,000 per violation per day as described in Public Resources Code <br /> section_42962. { // y/ <br /> �/t f 'r' 1,-/. <br /> r/.�\ �j• G. l�l'ti-'�'_.' %,- } �- C/�,� <br /> Representative Name(print) Representative's Signature Date 32876 <br /> Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ �■� <br />