Laserfiche WebLink
Aug 13 04 04: 55p @ 2094630199 p. 4 <br /> NINIF-r -is <br /> C <br /> 4 3415A„41` <br /> ■ California Integrated Waste ManagerrAnt Board <br /> CA Uniform Waste and Used Tire Manifest PO Box 1259, Sacramento,GA 95812-1259 <br /> i - .1 <br /> IF-IX XMIPILIE1 j112 31 Manifest Number <br /> State of California <br /> CIWMB-647(DO/03) INSTRUCTIONS ON BACK M 5 15 17 6 6 5 <br /> PART 1: TO BE COMPLETED BY TIRE HAULER(please print) <br /> J�(Pick Up <br /> [I Import from <br /> (11 outside California State/Country) <br /> 1 <br /> 17 Delivery <br /> S+L,)r_ A 1c; <br /> 0 Export to <br /> (If outside California State/Country) Hauler's Business Phone <br /> (include area code) <br /> Hauler Exemption (if applicable) <br /> E] Government ❑LEA Exempt <br /> Load Date (mmi[)D/yy) Log Number E]Agriculture ❑Common Carrier/ <br /> Back Haul <br /> Indicate(if applicable)0 In Transit <br /> 12A o <br /> leense Plate Number State Decal Number <br /> OConfidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential,proprietary,and/ortrade secret.In <br /> accordance with Title 14,COR,Section 17041 el.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 parially of perjury Linder the laws of the Slate of California that the irilorm"llion prof le 0ove is lose and correct. In addition,I ani aware that falsification of this <br /> Pur, <br /> information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler I pursuant to Put9vllesources Code section 42960 and may result in civil <br /> or administrative penalties up to$5,000 pei,Er-f V,.,,I <br /> perialbesupi()S25,mo per ay,parviolati s describ is Resources Code section 42962. <br /> Apo— <br /> - / <br /> K er's gignitur&--- Date <br /> Driver's Name(print) <br /> PART 11: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR W;S>TE TIRE GENERATOR OR END-USE <br /> FACILITY(please print) -USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. <br /> Business Name Facility's Business Phone(include area code) <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> E]Change Of Address <br /> City State Zip Code <br /> _�D Tire Types and Amounts Intended Use <br /> / 3 0 El Passenger ❑oversize [I Retread/Reuse <br /> Tire Program ID Site Suffix E] Recycle <br /> ra <br /> Load Type(check only one) 01her El Fuel <br /> ,Q Whole Tire Count Weight in Pounds <br /> []Volume Cubic Yards Weight in Tons ❑ DisposaULandfill <br /> Load Amount 0CL <br /> Comment Area <br /> []Confidentiality Claim: rhe information provided in Part I and Part 11 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 /> candy that under penally or perjury under the laws of Vie Slate of Cal;forn;a that the inlormadop provided above is true and correct.In addition,I Am aware that falsification of this <br /> niormalicin may result in civil penalties tip to$25,000per day,per violation oradministrative peria!ties up to _000 per violation per day as described in Public Resources Code <br /> secli 42962, <br /> �LZ/v),,- Z 6,A <br /> Representative Nahe(print) Representative' nature Date 32876 <br /> Tnll ;:rap i_Ai;r,_.qQA_nr%nn / wmhk riwirrih r:; noitfTirp.q/ == imi <br />