Laserfiche WebLink
CA Uniform Waste and Used Tire Manifest California Integrated Waste Management Board <br />PO Box 1259, Sacramento, CA 95812-1259 <br />JEXAMPLE J 111*273 Manifest Number <br />State of California I - 12 0 3 7 7 8 <br />CIWMB-647(03/03) INSTRUCTIONSON BACK M 5 <br />PARTI:TO B1= CQMPLETED BY, TIRE HAULER ,,_(,i� <br />L Ur),' <br />Pick <br />Hauler optonal - Address Label) <br />. . . . . . . . . . <br />Business Narner( ?I <br />0 Import from <br />(If outside California State/Country, Address <br />City, State, Zip <br />Expo't. <br />Hauler's Business Phone <br />L 4i� �_, J(_ <br />(include area code) <br />0 <br />-1 <br />Load Date (MM/DD/YY) <br />L I L-11 - <br />Log Number <br />License Plate Number State Decal Number <br />Hauler Exemption (if applicable) <br />El Government [:] LEA Exempt <br />El Agriculture 0 Common Carrier/ <br />Back Haul <br />Indicate (if applicable) E� ln Transit <br />ElConfidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential, proprietary, and/or trade secret. in <br />accordance with Title 1.4, CCR, Section 17041 et.seq, should any member of the public request disclosure.of this. information, I request that -CIWMB: contact <br />meat the address and telephone number above. <br />I certify that undee penalty of perjury under the laws of the State of California that the information provided above is true and correct. In addition, I am aware4hat falsification of this <br />information may result in suspension, revocation, or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil <br />penalties up to $28,000 per day, per at )day as described in Public Resources Code section 42962. <br />�vi violation or administrative penalties up to $5,000 per violati , on.per <br />Driver's Name Driver's Signature Date <br />.PART, II: TO -BE COMPLETED BY REPRESENTATIVE OF TIRE 15"RiMMM WASTE TIRE GENERATOR OR END -USE'S <br />LE, L,ITY <br />(please print' - USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED -UP OR DROPPE <br />[ro-p—lilln, j <br />FJ I /I I <br />Business Name Facility's Business Phone (include area code) <br />L—,t _J_1 I I I ') IJ <br />Number & Street Address <br />Address Same As Hauler <br />E] Change Of Address <br />City State Zip Code <br />Tire Types and Amounts Intended -Use <br />—1 - LI]0 Passenger El Oversize El Retread/Reuse <br />Tire Program ID Site Suffix El Recycle <br />I I I I • ELI <br />LLLoad Type, (checkl only one)[ 'Luck <br />1 � [J Other ❑ <br />Fuel <br />Whole Tire\A <br />,Count "eight in Pounds <br />Volume Cubic Yards Weight in Tons 56ispos,IlLandfill <br />,oad,.Amo <br />comment Area <br />FIConfidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential, proprietary, and/or trade secret. <br />In accordance with Tit�e 14, CCR, Section 17041 et.seq, should any member of the public request disclosure of this information, I request that ClWMB <br />contact me at the address and telephone number above. <br />I certify that underpenalty 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 pen4lfies up to $25,000 per day, per violation or administrative penalties up to $5,000 per violation per day as described in Public Resources Code <br />section 42962. <br />1w <br />2- -3 <br />RepresentatiName (print) Representative's Signature Date 32876 <br />7 Toll Free 1-866-896-0600 / www_ciwmh_ca_aov/TirPs/ r = owl <br />