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Aug 13 04 04: 57p @ 2094630199 p.5 a r l 4 J'I E x A M l�l r l � = Manliest Number State of calitorni1� 4 - fi 5 9 7 661 _-_4-__-__ CIWMB-647(03103) INSTRUCTIONS ON BAL;K _ PART I: TO BE COMPLETED BY TIRE HAULER (please print) Pick Up ❑ Import from ftf outside California State.Country) ❑ Delivery ❑ Export to 1 Hauler's Business Phone (If outside California Stale/Country) (include f 0 (� /6 _ (�/� area code) l / 6 Hauler Exemption (if applicable) / f ❑Government ❑LEA Exempt Load Date (Mfvl/DD/YY) Log Number Agriculture ❑Common Carrier/ Back Haut tGJ / s G' j� a _� �" �j Indicate(;I applicable)❑In Transit License Plate Number State Decal Number ❑Confidentiality Claim: The information provided in Part I and Part 11 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 disclosure of this information,I request that CIWMB contact me at the address and telephone number above. I certify that under penally of perjury under the laws of the Slate of California that the❑rforrnation provided hnve is true and correct. In addition,1 am aware that falsification of this inlormation may result in suspension,revocation,or denial of renewal of the Waste Tire Hauier Re on pursuant u e_ubh"esources Code section 42960 and riay result in civil penalties$2�day,per violat!on a mlrns:r�ahve penalties up to$5,001)per violali day as described Resources Code section 429 - Driver's Name(print) river's Signature Date PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY(please print) -USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. Business Name Facility's Business Phone (include area code) Number&Street Address ❑Address Same As iiauler ❑Change Of Address City State Zip Code Tire Types and Amounts Intended Use i o 1 CJ _ 0 ) ❑ Passenger ❑Oversize ❑Retread/Reuse Tire Program ID p� / Site(JSuffix ❑ Recycle Load Type(check only one) ❑Truck ❑Other Whole Tire Count ❑Weight in Pounds E]Fuel ❑Volume Cubic Yards ❑Weight in Tons O , a ❑ Disposal/Landfill Load Amount O Comment Area U ❑Confidentiality Claim: The information provided in Part I and Part If of this form should be considered confidential,proprietary,andrbr trade secret. 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 contact me at the address and telephone number above. 1 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 lalsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to S ,000 per violation per day as described in Public Resources Code section 42962. Representative ame(print) Representative's K4.alure Date 32876 ■ Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ ■ While'.CIMAS Copy Pink:Tirs DealerrGenerator?End-Use Facility Copv. Yellow:Hauler Copy FORM NO.V-104790-CR96lB 1.112 iim zz vu 76:I?