COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

California Integrated Waste Management Board CA Uniform Waste and Used Tire Manifest PO Box 1259, .Sacramento,CA 95812-1259 iKNOWw LeFEE7x Manifest Number .. r. : t ",te of C 7(11rnia 3,103 1 M 5 - 1 5 1 7 9 0 5 ea-s4,ioaJoai INSTRUCTIONS ON BACK ARTA: TO BE COMPLETED BY. :HAIIyk E lease;;pr� �Ri } Y STT r Pick Up �....y HSI (option -Address Lae ❑ Import floor r: r1 (if outside California C L;---;t�-'�� ��'` ; 't � / - .— � •`'` -„rut,, Tr Hauler's Business Phonet,ri > xc 4 v -- (include area code)`-- - �/J Hauler Exemption (if applicable) ❑ Government LEA Exempt Loadpate{MM/DD/YY) Log Number —1 --r— ---r—I --- -I- L_�� ❑ Agriculture ❑ Common Carrier/ Back Haul. n_' I f I_ _ Indicate(if applicable)❑ In Transit License Plate Number. State Decal Number - ❑Confidenilality Claim: The information provided in Part I and Part II 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"undefpenalty 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 information mgy, esult,in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up.t�$ 5i0.0d per day,pop, elation or administrative penalties up to$5,000 per violation per flay as described in P lic Resources Code section 42962. ` Driver's Name print) Drivers Signature Date RT II "T" FBE`CbMP TED B REPRESENTATl1/E OFI"IRE pE14 ER OR VI%ASTE?l IFiE GENER%xTq :CSW—N 5 5 A C__IL_LT.YjJ�a1�.�lsevgriCtt_1. .SE-AC�TPA J.Q:P! �QN _ T :rT� _5.. �, ..� .Q�u; Q ;9 Q1'P L��UF (optional-Address Labels _ Business Name Facility's Business Phone (includearea code) Number& Street Address ❑Address Same As Hauler. -_ —I L(--1/Y-1 L---1 L -L-J ❑ Change Of Address City _ State Zip Code --- -_ _ � ---- --- _ - -- Tire Types and Amounts Intended Use ❑ Passenger g _ ❑ Oversize ❑-'Retread/Reuse Tire Program ID Site Suffix { 1 ria /r Jecycle v \ I Load'iype{b"heck only one�j'h�fs� -- ---- �� E7 Truck FJ7 ❑ Other _ - , - ni- Wnofe TireCount ] Weight to Pouald 'r ❑ Fuel I-- �— I .El volume C ubio Yards, Weight to Tons O 1P ❑ Disposal/Landfill Load.Amout: O - Comment Area ❑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 f• -ntact me at the address and telephone number above. tify that under penalty of perju under the laws of the State of California that the i formation pr ided above is trfie and c rrect.In addition,I am aware that falsif -tion othis uuormation may result in civil pen Iti,_ up to 525,000 per day,per violation or ad D nr rative penal es up to S5,000 Per viola on per day as described in Public Res urces C�de section l / i / t , � Representative Name (print) Represe tafi�u�eis Signature Date 3 876 ® Toll Free 1-866-896-0600-/ ' www:ciwmb ca.gov/Tires/ NJhIJ.r' CIVVJLF r ld "LlJ Tire na;,io,c �d 1 m F---L y , ,v- %-.,I- ..— I-.