Laserfiche WebLink
Ar to <br /> California Integrated Waste Management Board <br /> A Urtiorm Waste and Used Tire Manifest Po.Box 1259, Sacramento,CA 95812-1259 <br /> ■ �= X A M P L Manifest Number ` <br /> State-of cettfornla r 8 - 1 4�1 -8 4 3 7 <br /> cfwala-ea7(oafa+t INSTRUCTIONS ON BACK L___ <br /> BI4 C+�511ti� <br /> I Pick Hauler R (�,rotional- 4dresti!_at :1) <br /> �. <br /> Susines lVdt7lt? r <br /> I...l 11 nhcilfiYnn1 <br /> (if putsi' e Address <br /> fi <br /> Deliv('t-y i.ity, State. Zip <br /> l E.x'x"tt tc <br /> Hauler's Business Phone f <br /> lit n ft y lc (include area code) <br /> Hauler Exemption-(if applicable) <br /> ❑Government [1 LLA Exempt <br /> Load Bate (MM/DDIYY) Log Number F1 Agriculture 0 Common Carrier/ <br /> Back Haul <br /> `F =i (1.- - _ Ir1dlCate(if applicable) In Transit <br /> 1L_L, _Y J <br /> License Plate Number _ _ _ State__ _Decal Number <br /> []Confidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential,proprietary,and/or trade secret.In <br /> accordancewith Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure.of this information,'[request that CIWMB contact. <br /> me at the address and telephone number above. r <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 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$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. <br /> Drivers Stu <br /> Driver's Name re Data <br /> r ..iii It, TO BEnCOMPLETED BY REPrF_SI N'T AT1VC" IftETWAL <br /> TR� � � U� �CAIION WHEFE'l � PQ 3 � �FCOFF <br /> l�( tion!-•Acfdresslabe�t) <br /> Business Name — Facility's Business Phone (include area code)' <br /> L I _i­._t__--� <br /> Number&Street Address, ry <br /> f ,. Cj Address Same As Hauler <br /> i ❑Change Of Address <br /> l.-_...,_1....__.1�._.1.._.;`;�: °`;l_,_.1:....�_L:,_�:1-----_.L._..J__-i�`_1._.._h�.:L_._t__._t•.,J i�'�_.t.:_`-`� l__ 1 _t. l — . <br /> City Smote Zip Code <br /> - - I - - Tire Types and Amounts Intended Use <br /> I1 Passenger ❑oversize ❑Retread/Reuse <br /> -T--7- r—- <br /> Tie mPrc�cfram ID Site Suffix (� i <br /> Recycle <br /> ' Other Dad Ty7r ❑Truc _ Fuel <br /> wetow in f I [--- / Disp IILandfill <br /> r <br /> Load.. <br /> Comment Area { <br /> s <br /> []Confidentiality Claim: The information provided in Part I and Part If of this form should be considered confidential,proprietary,and/or rade 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 penalties up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. <br />