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■ .... CA Uniform Waste and Used Tire Manifest California Integrated Waste Management Board _ PO Sox 1259 Sacramento,CA 95812-1259 ■ C_L"J_^lY� P L E 1 2 3 Manifest Number ....... State of Califomia ciwnaa-say fnaro3l INSTRUCTIONS ON BACK 8` 5 Q V 81 0 6 ] PART 1 C ~ k UP` Hauler (optional. pnrt fro -Addwess Label) (( a ;. i,. Business Natrel m . .> ,. IFIL 1053-BOARDWALK D, Address R. e` City, State, lip _ ToCKTON, CA 95206 . j nt+t _ _ 209-9$2 .9408 _ (inc u Business Phone T - (include arLJ Haea code) il r . , Hauler Exemption (if applicable) RC1 ❑ ❑ 10-'g'- 'Number Government LEA Exempt Lbad Date (MWDp�) - �. _ _ ___ _..__r_. ❑Agriculture 0 Common Carrier/ _ Back Haul •. � _� 1 l. I�J..�. . .�*. 1 {/ _ Gay t Indicate(if applicable)i�In Transit [6d I�y� License Plate Number State Decal Number ❑Confidentiality Claim: The information provided in Part I and Part If 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'perialty 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 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 ra dit in evil penalties up to$25,000 per day,per violation or admini rative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. 1� '. , .4- Driver's Na me li„unto `� river's Si nature f'AHT 11. "F0 R + n iOR � f�EtUEI�AT®Fi,(af� L4+tCJ-1DSl= itGIL,I"T1G.4 1 Fii�ttl - A '1 ? A It3{# VE<', ,tiE_�'IRE f . ._ r. M I W 51 Businest-Name Facility's Business Phone (incl de area code) _.___,.;_.�.____L _L-1___J_-J Number.&Street Address ❑Address Same As Hauler L_. lcJ !-7 1_j�L _ L1__—�_1 �_ _ J�.� l�_.L____J �LJ ❑Change Of Address City State Zip ode T ^ �/� Tire Types and Amounts Intended Use -_L(' 3� � 1 •il•--i .Passenger ❑Oversize _ . ❑Retread/Reuse Tire Program ID Site Suffix 11- f_J -[_� I^ — � 1 ( {�j Recycle z, ?� r' ❑Truck ❑Other 1 Wholo Tim Coon! � 77 - - �-__ _ ❑Fuel �'olnni� t uhr:4, . IT] ❑Disposal/Landfill d Arttgt.tn�` ----- F-7- aa Comm t Area ❑Confidentiality Claim:The information provided in Part I aJP .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 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 information may result in dyil penalties.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 section 42962.