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..afomia Integrated Waste Management Board ■ CA Uniform Was a and Used Tire Manifest PO Box 1259, Sacramento,CA 95812-1259 ■ �� X A M P L E 1:.1-2131 Manifest Number a .Ie State of Calirnrhia INSTRUCTIONS ON BACK r ` �M 1 - 14 51 7 4 CIWMB-647(03103) _ POARl•t: To 13E COMPI IE-TE D RV li IAt ` prim a �]`�icic Up , _..�-1rt (dptec�rfal-AddraJ -- Bi�siness Hartel � � D I_I 11,I)POIJ tiOltl (lf LI ICI" —.lifulrim S 1tF OlR1f Address DEC 1. �u1 —� - 1053 BOAi /ALK DR. Delivery ' City, State, Zip E O4�E� 5206 if uu1,c�Ju.( 11ft rrJi Hauler's Business Phone —L- ment - . (include area code) ( L. •, F ~- �� -. -- -�- Vii -� .- - Hauler Exemption of applicable) -7 r. ❑ LEAtxem t p Loa `Date (MMAMNY) Log,Number ( ❑Agricultuar 11Ogmmon Carrier/ I l { Baak Haul . C) Indicate tri ar;plfcaf�ie)U In Transit License Plate Number __ State Decal Number [DConfidentfali Claim: The information ro-�V-..---_-----___.___.___.__�_ ty provided in Part 1 and Part 11 of this form should be considered confidential,prdprietafy,and/or trade secret.In accordance with'T ltle 14 C*Ri Section 17041 et.seq,should any member of the public requestdisclosure of this information t request that"CIWMB contact .,(ne at fhe address and WO.,lone number above. I �rHty that under penalty of poi 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 fnf ation may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resourcei,Cboti section 42960 and may result in civil penAles up to$25,000 per day,per ylgtation par administrative penalties up to$5.000 per violation per day as descf{bed in Public Resou s _ e,section 42962:- Driver's N Ime(print) to rr� Date l e O FWXIINIPLETED E)Y FIEPRFSIEN1 Of-1 WA:E: `tiRE GENERATOR OR F--ND-USE FA -PE ACTUAL LCA( Ar; i3( W;flEr?#u THE -fiRES AHI .Y(t K.F—Q-JUP 13F3.,UHQ#'PLU t..+4-, (optional--Address Lakrc=o Business Name ° 1. Factilit s Business Phorte(t`elude area cod, r &{ F `1_ 1 L t__ '. , ., �i: .if�. L_ _1 Y�-i_.�.___L L__ !___i_ `L.._ i _i A_L_, _ ► i _i_.._L�L�.1�J Nu1ber ;Street Address , [;Address Same As Hauler L.._y.�J._..__.1.�.�1_� Change Of Addre.�s City State Zip Code Tire Types and Amounts Intended Use ❑Passenger ❑Oversize ' � �. � ❑.Retread/Reuse Tire Program ID Site Suffix -� k _ ❑Recycle .s FIT- 0 _.- t..©aef .I"yPe fr1,r: �s Truck O Other Fuel DD. isposaVLandfifl"��av Load /"+,rniount Comment Area pConfidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. 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 contact me at the address and telephone number above. I certify that under penalty of penury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware ihatUsfigation of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Rosourcbs,CpAe section 42962. e Por%rncontativa Klnmp r.,.r.,+, RpnrAQPntativP'C Sinnattrrp rfatp