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05/01/006 09:09 2099330299 VALLEY FOPk'LIFT PAGE 05 _T <br /> . � � CA Uniform Waste and Used Tire Manifest CslitomlalnregrdleOWasteMenegementBpgrd <br /> PC Box 1259. Sacramento,CA 95812-1259 <br /> 'n E X A N P L �' Z 2 3 A� Manifest Number <br /> clwme.�"j opt INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE M 4 ` 2 1 V '5 2 3 8 <br /> By signing ihlg CA Uniform W este and U ped Tine Manifest.the signer(s)requests that the information provided on this form win be Considered confidentlal,proprietary and/or a trade <br /> secret. In accordance with Title t a,CCR,Section 17041 et seq.,if a request is made for disclosure,or trii;information,the CIWMB will contact the signer(s)of this form at the address <br /> and telephone number provided on INS manift+st- <br /> PART I: TO BE COMPLETED BY TIRE HAULER I PLEASE PRINT FIRMLY <br /> XPick Up ADelivery <br /> V— <br /> Please complete if outside California <br /> ❑ Import/Export <br /> Hauler's Business Phone <br /> State/Country (include area code) ( 1 l 0( ,3 J <br /> Load Date (MMIDD/YY) Log Number Hauler Exemption(if applicable) <br /> 5L( 7 j /�-/1 7 � � ❑Govemment El LEA Exempt <br /> o (/ ( ❑Agriculture ❑Common Carrier/ <br /> License Plate Number State Decal Number Back Haul <br /> 5 7 � 7 � � �/ � � O � _ � � �. Indicate (Il apvi+cebre) <br /> L [Xn Translr ❑ Unregistered Hauler <br /> I cert fy that under penalty of penury,under the law;of the S!ate of Caidorml that the mferm.avon provided above Is true ane Correct. In addition,1 am Aware that falsification of this <br /> information may result m Fu3pension,revocation,pr denial of renewal of Trip Waste Tire Hauler AFglstr�itior pursuant rC PoOliC Resources Code section 42960 and may result In Civil <br /> penalties up to$25,000 per Oily,per violation o•adminislr,live penalties„p ro$s,00c per vio ay aYes ibed In PUNIC Resources Code Bf.CUpn 42862. <br /> r <br /> D i 'S Name(prinq ri s Signature Dilate <br /> PART 11: 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 /> i/ ha /,v-- 1 if _ <br /> Number& Street Address <br /> �t I fr3 S G � L � � <br /> y State Zip Code <br /> AQtlresa Same As Htulgr <br /> Fr S �—c'" C � � rS 7 d2 S <br /> ❑ Change Of Address <br /> Tire Program ID Site Suffix Load Type (check only one) Load Amount <br /> ! 3 1-t 4 E]Whole Tire Count Weight in Pounds 5 a ■ <br /> ( a Volume Cubic Yards Weight in Tons whole Numbers only Decimal <br /> for Whole Tire Count <br /> ;fl Passenger Amount Ovcrslze Amount Intended Usr' <br /> q ❑ Retread/Reuse Recycle Puel *Dlsposal/Landfill <br /> O <br /> Truck Amount Other Amount Comment Area <br /> tZ <br /> O ■ ■ <br /> I certify that under ponahy of perjury Under the laves of the State of Cal;rornie that the,Information provldSd above Is true and correct.In addition.I am aware that falstftcAtion of IhiS <br /> information may reguit in civil penalr;ot up to$25.000 per o;ty,per vlolation or administrative penalties:up to$S.Oocl pe_r, v o1.tion per day a described In I'utN;c Avaources Code <br /> section 42962. <br /> Repress alive Name(print) rintative's Signature Date 26187 <br /> Toll Free 1-866-896-0600 / www.ciwmb_ca.covfTirPc/ 16 0 M I M <br />