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CA Uniform Waste and Used Tire Manifest p1'Icrn'a 111egM10al Waste Management 5oard <br /> PO Eox 1259, Sacramento,CA 95812-1259 ■ <br /> EXAM I P L E I 1 IZ 3 Manifest Number <br /> M� <br /> ciwboaf-a4?(nest INSTRUCTIONS ON BACK DO NOT TAPE. STAPLE OR DUPLICATE 1YI 2 - 2 10 52 36 <br /> By signing this CA Uniform Waste and Used Tire Marnlo n,the signer(s)requests that the mforntatlon provided on this form will be Consi Yered confidential,proprietary and/or a trade <br /> egret. In evcorUnnce with Title 14.CCf9,Section 17041 et seq.,if a reque3t is made tar disclosure of this information,the CIWMB will Contact the si9ner(s)of this form at the addfuss <br /> and telephone numoer provided on this manifest. <br /> PART I: TO BE COMPLETED BY TIRE HAULER PLEASE PRINT FIRMLY <br /> Pick Up X Delivery <br /> Please complete if outside California <br /> ❑ import/Export <br /> HBusinessPhone <br /> State/Country (include area code <br /> Q � O <br /> Load Date (MmMiYY) Log Number Hauler Exemption(if applicable) <br /> L7O / ❑Government Q LEA Exempt <br /> [I Agriculture 0 Common Carrier.: <br /> License Plate Number State Decal Number SacK Hal.l� <br /> u 7 Z n lndicate (if applicable) <br /> J �J �( (� in Transit ❑ Unregistered Hauler <br /> I certify that under penalty of perjury under the law.,of the State of California that Ni information provided a0ove i.�true and Correct. In addthor I am aware that faisificalion of this <br /> information may result in suepel's,on,re'+oCatlen,or defdal 01 reine'wai of thu Waste Tire Hauler -vauon pyrsuart to Puhiic Resources Codu section 42960 and may result:n civil <br /> oenau:es up to$29,000 per day.per violation or aominlsuaovG penalties up to s5A00 per vi d anon pe day s describe I bhc Resourzes Codu section 42962 <br /> Driver's Name(print, ri 's gna u e Date <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. <br /> USE ACTUAL LOCATION WHERE THE TIRE$ARE PICKED-UP OR DROPPED OFF. PLEASE PRINT FIRMLY <br /> Busin ss Name Facility's Business Phone (include area code) <br /> W�6 Lc 5,�Ze, L $ Cl - <br /> Number & Street Address <br /> _3 1 _3 S G o L off' e 5 %.� i F L ,,. d <br /> City State Zip Code ❑Address Same As Hauler <br /> r� //� /v/h s ''7 <br /> l e i � CT lt/ ! J / ❑Cnange 01 Address <br /> Tire Program IO Site Suffix Load Type (check only one) Load Amount <br /> / <br /> 21, <br /> kt 3 - l �Whole Tire Count L]Weight in Pounds '7 <br /> • <br /> Volume Cubic Yards❑Weight in Tons Whole Numbers only Decimal <br /> for Whole Tire Count <br /> Passenger Amount Oversize Amount Intended Use <br /> ❑RetreadiReuse Recycle 04el [ isposal/Landhil <br /> Comment Area <br /> Truck Amount Other AmOunf <br /> 0. • • <br /> 0 <br /> 1 cenify that under penalty of perjury undur the laws of the State of California than the Inlormatton provided awve Is true and Corruct.in addition,1 am aware that ialsillcation of this <br /> information may result,n civil penahle9 up to$25,000 per day,per violation or adminivrative penalaez up to$5,000 Der violation or r day as described in Public Aesources Codu <br /> section 12962. <br /> Representative Name;print) Representative's Signature Date 26187 <br /> . Toll Free 1-866-896-0600 / WWW.CiWmb.ca.gov/Tilres/ <br /> White CIWMB Copy Pink:Tire Dealer/Geoer9toreEnd-UNc Facility Gopy Yellow:Hauler Copy <br /> VO 3917d l.=II-11d0-�1 A3-17V/% 66319CC660Z 60:60 900Z/Z0/S0 <br />