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CA Uniform Waste and Used Tire Manifest CaPomBox 11259. SSa aamen[to CAe95812-259 <br /> L E 1 2 3 - Manifest Number 0 <br /> c,wi awl INSTRUCTIONS ON BACK DON TAPE STAPLE OR DUPLICATE M 3 - 2 10 5 2 3 7 <br /> By signing This CA Undorrll Waste and used Tire Manliest,the signer(s)requests that the inl0nt1allon provided on this Corm will be considered confidential,proprietary and/or a tr9de <br /> S6crut. In accordance wilh Tillu 14,CCR,Section 17041 at seq„if a request is made for diaclos4re of this information,the CIW MB will contact the signer(s)or this form at the address <br /> and telephone number provided ort this manifest. <br /> PART I: TO BE COMPLETED BY TIRE HAULER _ <br /> PLEASIE PRINT FIRMLY <br /> Pick Up Deliver (f'��' cerf ' <br /> Please complete if outside California <br /> Fre,,ter 7 <br /> ❑ Import/Export <br /> ,7 '7,f.-'2- QS <br /> Hauler's Business Phone <br /> State/Country (include area code) <br /> { ;zlip <br /> ) - © l e <br /> Load Date (MM/DorvY) Log Number \\\ Hauler Exemption(it applicable) <br /> I t � / � � L7 <br /> - I � �� �r � ❑ Government ❑LEA Exempt <br /> License Plate(/Number State Decal)/Num !/ /V/ ❑Agriculture ❑ Common Carried <br /> bei Back Haul <br /> 57 2 (� " 4 O0 3— _ v/� 5 p 1t S —01 <br /> Indicate (if applicable) <br /> C•r n Transr[ ❑ unregistered Hauler <br /> I certify that under penalty of puriury under the laws of the State of California that the information provided above's tr a and c CI. In addflion.I am aware that falsificatio t of In.;z <br /> information may result m SUSp8n3iun.revocation,or denia,of renewal Of Inst Waste Tire Hauls g st on pur "ant to P e3ou�ces C00e Suction 42960 and may result in civil <br /> penalties a to S25.Ooe per,�ay,por violation or administrative penarae'v up Io 55.000 per vi lion pEr tl .i3 'scribed i ub c riillisourc eS Code section 42962. <br /> Driver's Name(Print) I sS naturle Date <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 /> Buss f®� t?, E� lr Facility BUSIne5i5 Phone (include area code) <br /> q 94 r� s Z <br /> Number& Street Address <br /> 2l �J` �61 G a L <br /> Ity State Zip Code <br /> ❑Address Same A5 ftiaufe;r <br /> S ❑ Change Of Address <br /> Tire Program ID Site Suffix Load Type (check only one) Load Amount <br /> 3f 3 1? Whole Tire Count Weight in Pounds <br /> `f ( Li Volume Cubic Yards F]Weight in Tons Whole Numbers only ■ Decimal <br /> for vines Tire um <br /> Passenger Amount Oversize Amount Intended Use <br /> Q [� Ratreau/Reusecycle Fuel oelSpOsal/Lan til! <br /> Comment Area <br /> C Truck Amount Other Amount <br /> CL <br /> O ' - <br /> t Certify that under penalty of perjury under the jaws of the State of California that IhU information provided above iS true and corrcCt.In addition,I am aware the falgiltCatlOn of Ihis <br /> Information rnay res.dt in civil punaities up to s25,000 per day.per violation or adminrstrai,ve penalU6s up to$5,000 per violation per da a descnoeo in Public Ftesou <br /> section 42962. Y' I r�eS Code <br /> Repr ntative Name(print) Arentative-s Signature Date 2sis� <br /> Toll Free 1-866-896-0600 / www.Ciwmb.ca.gov/Tires/ <br /> White:CIWMS Copy PInK:Tire DeataoGdnerator/End-Use t acillty Cupy Yeuow:Hauler Ccrpy <br /> 710 391it'd 1%37-1VA 66-60CC660( 60:60 900L/T0/S0 <br />