Laserfiche WebLink
:"1 t� f.A. Jr'vi..•��;r i 'H�'r� !► ".>�r�:" ♦ _S x ' <br /> CA Uniform Waste and Used Tire Manifest """BOA <br /> t1259.lod ra a Ito.CA mentBoard ■ <br /> PO Bo c 1258. Sacramento,CA 95812.1259 <br /> ..3 ELX A M P L E 1,2 3 1 Manifest Number <br /> CIW °-G47(1 0 INSTRUCTIONS ON BACK DO NOT TAPE.STAPLE OR DUPLICATE M9 - 2105234 <br /> CIWM6.647(t0A3) <br /> By signing This CA Uniform waste and Used Tire Manifest,the signer(sl requests[hat the information provided on tills form Will W,ConSiCUred Confidunfial,proprietary ardror a trade <br /> secret. In accordance with Title 14,CCR.Secticn 17041 st seq..it a request is mai for disclosure of this informawn,the CIW MB wilt COMW the Signers)of this form at the address <br /> and talephonc numbar provided on this manifest. <br /> PART 1: TO BE COMPLETED BY TIRE HAULER PSE E P INT FIRMLY <br /> �/�t-LLQ LIFTS <br /> xPick Up Deliveryj- <br /> - - / <br /> Please complete if outside California (1-\Z <br /> Import/Export <br /> HaulerePhone <br /> State/Country (include area code /� D <br /> Load Date (mm/oowv) ' Log Number Hauler Exemption(if applicable) <br /> ❑Government ❑LEA Exempt <br /> © .� D L7 70201 <br /> ❑ Agriculture E] Common Carrier <br /> License Plate Number State Decal Number Back Haul <br /> 7 _ /�j 4 Indicate (if applicable) <br /> 5 C O S v J ! � 7 �i <br /> 7 n Transit ❑ Unregistered Hauler <br /> [certify that under penalty of perjury under(he laws of the Slate of Ca[ilornia that the information provided stove is true and correct In addRlon,I am aware trial fals,fical on 01 Ih's <br /> information may result in SuSpenaion,revocation,or d2nial of renewal of rhe W a5tt Tire=RegIST(dflon ;int t0 Pudli %%wol ceJ CO a SCCfI0r1 42960 and Indy re*olt in civil <br /> penalties up to$26000 per qay,per violation or adminimrswe penalties up to$5.000 pCrlbed 'public R' our, Ude section 32962. <br /> oriAti Name(print) e Date <br /> PART If: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END•USE FACILITY. <br /> USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. PLEASE PRINT FIRMLY <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> Tr.), -IL Lvz� <br /> City state Zip Code ❑AodreoS same AS Fi ulcr <br /> L-< S N G LJ)Ily t,�; Cnao9e or address <br /> Tire Program ID Site Suffix <br /> Load Type (check only one) (Load Amount <br /> 3 L4 4 3 ❑Whole Tire Count �Weight in Pounds Q <br /> F]Volume Cubic Yards a Weight in Tons Whole Numbers only Decimal <br /> for Whole Tire Count <br /> :4 Passenger Amount Oversize Amount Intended Use <br /> Q <br /> ❑RetreadlRouse Recycle Fuel Disposal/Landfill <br /> r ■ <br /> Comment Area <br /> = Truck Amount Other Amount <br /> O <br /> o ■ <br /> 1 certify that under penalty of perjury under the laws of the Stale of California that the information provided 400ve i;�truo and Corrud In addition,I am aware that fufaification of this <br /> nformalion may result in civil penalties up to 325.000 per day.per violation or administrative penalties up to$5,000 per votatlon per day as ciescooed In Puollc Resource:;Code <br /> section 42962. ( <br /> ' is' <br /> - Ow I <br /> Repress ative Name(print) R tative's Signature Date 26187 <br /> Toll Free 1-866-896-0600 / WWW.CiWMb.ca.govfTilres! � <br /> i;0 39Vd 1dI_1.A60J A317hA 60:60 9001/Z0/S0 <br />