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Aug 13 04 04: 57p 0 2094630199 p. 6 <br /> EXAMPLE '2N <br /> Manifest Number <br /> ,oniocNffie-547(o,!03) INSTRUCTIONS ON BACK OM8 - 1517668 <br /> PART 1: TO BE COMPLETED BY TIRE HAULER (please print) <br /> ,Pick Up <br /> ❑Import trom <br /> (If outside California State'Country)I n <br /> ❑ Delivery <br /> ❑ Export to <br /> (If outside California State/Country) Hailer's Business Phone <br /> Include area code) <br /> Hauler Exemption (if applicable) <br /> / 6 ❑Government❑LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> ❑Agriculture ❑Common Carrier! <br /> Back Haul <br /> S -- Indicate(it applicable)❑ In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidenliality Claim: The information provided in Part I and Part Il of this form should be considered confidential,proprietary,and/or trade secret.In <br /> accordance with Title 14,CCR,Section 17049 ef.seq,should any member of the public request disclosure of this information,I request that CIWMB contact <br /> me al the address and telephone number above. <br /> I certify that undet penalty of perjury under the lays of the Stale of California that the information provided ove is true and c In addition,I am aware that falsification of this <br /> information may result in suspension,revocation,or denial of rerinwal of the Waste Tire Hauler Registia pursuant to P Ic asources Code section 4 and may result in civil <br /> penalties up to S25,000 per day,per violat or administrative penalties up to 55,000 per violation p ay as descri in tic Resourres Cade sr n 42962. <br /> --- — <br /> r er s Name(print) f e_s f� ure Date _ <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WA IRE GENERATOR OR END-USE <br /> FACILITY (please print)-USE ACTUAL LOCATION WHERE THE TIRES ARE RIC D-UP OR DROPPED OFF. <br /> 6 <br /> mess Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> ❑Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> �( (� ❑ Passenger ❑Oversize ❑Retread/Reuse <br /> Tire Program ID Site-Suffix <br /> _ ❑ Recycle <br /> Load Type(check only one) i Truck Fuel <br /> ❑ g ❑ ❑Other ❑ <br /> Whole Tire Count Weight in Pounds j C <br /> Volume Cubic Yards Weight in Tons ,O <br /> ❑ Disposal/Landfill, <br /> 06Load Amount <br /> i � Comment Area <br /> ❑Confidentiality Claim: The information provided in Part I and Part If 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 lav,s of the State ofCalifornia that the information provided above is true and correct.In addition,I am aware that falsification of this <br /> inlormation may result m civil penalties up to$25,000 pef day,per violation or adminislrative penalties up lill,$5.01x)per violation per day as described in Public.Resources Code <br /> sectien 2362. <br /> Representative N e(print) Representa�Vw <br /> ignature Date 32876 <br /> ■ Toll Free 1-866-896-0600 / .ciwmb.ca.gov/rires/ ■ <br /> White:CIWMB Copy Pink Tire DealeriGenerator,End-Use Facility Copy Yellow.Hauler Copy <br /> vc;114 NO.M.1tW744"CMUO r.5i[IGM 222 Pit 76 Sai <br />