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DEC-22-2005 11:19 FLEET SERVICE P.02 <br /> _ oia lntegmted Wal Management Board <br /> Uniform Waste and Used Tire Manif®st PO�Ma�nifest NUMber9�t2-,zss <br /> CAEXAMPLE 1 Z3 r469. 366] <br /> INSTRUCTIONS ON BACK <br /> Hauler I(optional-Address Label) <br /> E31.1siness Nafne( I_':�, , .,r.,�.._ % 7 <br /> Address <br /> City; State,Zip i uG.4�'�'�'�'' <br /> Hauises SMiness Phone `� <br /> (include area code) `- <br /> - ~� hauler Exemption (if 41`0 8bie) <br /> ❑Government❑LEA Exempt <br /> � �� on Carried <br /> G re. Comm <br /> (� 1 -- <br /> Agriculture, ❑ <br /> • Log Number Back Haut <br /> Load Date (MM/DD/YY) indicate(if ePP'T <br /> applicable)❑In Transit <br /> l.�L] <br /> } State Decal Number md <br /> License Plate Number _ proprietary.and/or trade secret.in <br /> gConfld Ity Claim e informal on provided in Part I and part II of this form should di Considered is Information. <br /> accordance e with Title CCR,Section 17041 el.seq,should any member of the public request disclosure of this lrtformation,S request that Cl1NMt3 contact <br /> meat the address and telephone number above, is true and correct. to addition,I am aware that tel ritlCatlOn of n C, <br /> I c0ntfy that under per's ty of pad ry istration pursueM to Public Resources Code section x2900 and may result.to ciV6 <br /> 1 u under Ina laws of the Si3te 01 Gal lOmla that ate informer PrOwdsd above <br /> irttORnaliOn may result in suspenaton,revocation,or Oeniel of renewal Of the Wage Tire Haybr F r day as deeaibed,in'Public Rayourcos Code eactton 42962• <br /> inlomme6 uP t0$25.000 Per day,per vi0lauon or administrative Pell up toPeri $5,t>DO per Pa <br /> - <br /> V. Z1 t -0ate <br /> l - Driver's St nature ` <br /> nrivaea Name rint <br /> (optional-Address Label) <br /> Facility's Business Phone (include area code) <br /> Business Na <br /> aul <br /> Number&Street Address p °�' sem°re s <br /> cl: r >.��_ •.►—�1�!-1--,-.'� State Zip ❑change Of ndereea� <br /> de <br /> City Intended Use <br /> • tine Types and Amounts �RetrAad/Reu6e <br /> Q.Passenger ❑oversize _ <br /> Recycle <br /> site suffix <br /> Tire Program ID _ L —� <br /> p-rrudt pother D Fuel <br /> IZ7 <br /> I , )plsposal/Landtill <br /> I— 1 <br /> •Comment Area <br /> ..—. <br /> rietary,andJor trade secret. <br /> n 17041 et.seq,should any member of the Pubf�request disclosure of this Information,l request that CiWM6 <br /> OCpn1<itlent�8lity Claim'. inforlill Provided in Part I and Part 11 of this form should be Considered confides D*oP <br /> in ao=dance with Title 14,CCR.seWo <br /> contact me at the eddril and telephone number above- above Is true and correm.in addtdw I am aware That� bn d katINS <br /> of Carrfomla that the irdon"stion tNO <br /> t0 52Sws o per day,Par Violation Of admktiatrallve pertaitlea up to 45,000 per violation per day asdescrlt�d in PuPublicResources Gil <br /> I certify"I ul pPailof Pe"under <br /> the taws of the State <br /> vi4ed <br /> innn <br /> rpelian may result in dwt penallies UP <br /> 2. Y ' <br /> scabs 4298 �: C ( � t <br /> -i(; t �) i L ----� ._ Date 32876 <br /> TOTAL P.02 <br />