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rt alifornia Integrated Waste Management Board <br />■ CA Uniform Waste and Used Tire Manifes PO Box 1259, Sacramento, CA 95812-1259 ■ <br />7 <br />E X A M P L E 1 3 Manifest Number <br />State of California. <br />INSTRUCTIONS ON BACK 12 0 3 7 0" <br />CIWMB-6" (03/03) - - <br />lel' <br />siness Name <br />dress <br />_. ' +gal Address Label) <br />E,.. <br />y, State, Zip I <br />ler's Business Phone <br />include area code) k <br />Hauler Exemption (if applicable) <br />❑ Government ❑ LEA Exempt <br />Load Date (MM/DD/YY) Log Number <br />❑ Agriculture ❑, Common Carriar/ <br />Back Haul <br />Indicate,(if applicable) ❑ In Transit <br />License Plate Number d State Decal Number <br />�_ <br />❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,,propt;etary, and/or trade secret. In <br />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 <br />rn.e at the address and telephone number above. <br />rce.rtify that under penalty 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 <br />information may resOt in suspension, revocation, or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in'civii <br />penalties up to $2p,009 per day, per violation or administrative penalties rup.to,$5,000 per violation per flay as described; Public Resources Code section 42962 <br />DrivEr's Name (print) Driver's Signature :? . Date <br />Business Na <br />Number & St <br />ty� <br />4 <br />=_m <br />Tire Program ID Site Suffix <br />= MMM EN <br />Facility's Business Phone (include area code) <br />❑ Address Same. As Hauler <br />❑ Change Of ;Address <br />State Zip Code <br />Tire Types and Amounts Intended Use <br />❑ Passenger ❑ Oversize ❑ Retread/Reuse <br />,Truck <br />Commen <br />. ❑ Recycle <br />❑ Other ❑ Fuel <br />. m • m ®!Disposal/Landfill <br />:Area <br />❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential, proprietary, and/or trade secret. <br />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 <br />contact me at the address and telephone number above. <br />I certify that under penalty 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 <br />information may result in civil penalties up to $25,000 per day, per violation or administrative penaltie(s up to $5,000 per, violation per day as described in Public Resources Code <br />section 42962. % <br />r <br />Representative Name (print) Representative's Signature Date 32876 <br />o Toll Free 1-866-896-0600 / www.CiwMb.ca.gov/Tires/ _m = <br />3 <br />