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California Integrated Waste Managerrlent Board _ :.. CA form Waste and Used Tire Manifest PO Box 1259, Sacramento,CA 95812-1259 �v -. Manifest Number.... EX, P L E 1 2 3 ' r 6 -"� �,,,I .r C,,ili0'1/: INSTRUCTIONS ON BACK 06 . 1 41 6 (:I VIP I[1(,.17 jilt/ll'1) - 1..._._-_�._�.-._._,_._. .__--..._..____.�..._......�.-.-J PAM is TO BE COMPLE'ift1 1 Y lF[ HAUL; *si, 3'lQ `.� Pick Up i(optional-Address Label) Business Narnel maR COMPANY C] 1rrlh0rt fto(n A 1053 Boardwalk Dr. ,l r,ltix!< : ,III tnt i Atacirs Stockton,CA 952206 � I Deliverycn" stats , Zip (209)982-9408 --1 _. y _.� I-I Exnart to III=I�t uic r:tlttcul�e3 St tle� Hauler's Business Phone (include area code) } ` C Hauler Exemption (if applicable) t �� I L4 ��y _ ❑Govemment❑LEA Exempt Load Date (MMJD Y) Log Number ❑Agriculture ❑Common Carrier/ - Back Haul tf� - l A j Indicate(it applicable)E] In Transit �_ Number License Plate Nu_br _ _ stateDecal Nube _ _ _ ❑Confidentiality 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 undor'ponaltp'of perl'ury'under the laws of the State of Califomis-ifibt the information provided above is true and correct. In addition,'I am aware that falsification of this information may rasult_in spe'nsion,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 r r day,per violation or adminis five penalties up to$5.000 per violation per day as described in Public Resources Codo suction 42962. Driver's Name(print) C Driver's Signature Date PART 9i r La �l� CC7�(i�'1.1�Y, f�i��AtzrlI��LOe��r�L ctt=tom �u�s,� .:�.�� l�A�C)1�1✓I��t fit. USE AC it*¢, ")ON WlA - _ r(opyo;ial / �_ . � Business Name Facility's usine4 Phone (include area code) L_ ._L..ia��lG�i_ !..I _j.l__._-_��__��.._._1�__ Lt..11.._!.__Ci_'._��.�_ 1.___.._.I_: -----•.f-----�--- ' i.__._._L.:�l....�J_,._....-.1----1---1•----1.._.._.1 Number&Street Address _ -. i-�` ❑Address Same As Hauler 1..�`,�t-.-,r�J t--:.5_._I E]Change Of Address . I__�l ��_...1__`_.��!_�.L__._L.�_.C_._._.t...__1._:.-•-'~---I----=-�_i:.......__L_._.1�_.l L._� .,f-�t-- City _State Zip Code Tire Types and Amounts Intended Use y I . ! (j •2 % (��'� f ❑Passenger ❑Oversize ❑Retread/Reuse Tire Pi o(ar0 Recycle 3m ID Site Suffix + 1� i j z> __ _ _ f__.1-EL] Load Type (o); k )Iy. ❑Truck ❑Other ❑Fuel. j U(Ilurtir, r tri„�, r Disposal/Landfill Load ArrtU Comment Area ❑Confidentiality Claim:The information provided in Part I and Part 11 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 penally of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware thatfalsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penaltigs up to$5,000 per violation per day as described in Public Resources Code section 42962.