Laserfiche WebLink
' CA Uniform Waste and Used Tire Manifest` C2lifomia Interaled Waste Management Board ■ <br /> ,_-- — PO Box 1259, Sacramento,CA 9M12-1259 <br /> E X A M P L. E 1 2 3 - _Manifest Number <br /> Siete of Cntifornia 9 41 8 .3 41 , <br /> C0AVU-647(03/03) INSTRUCTIONS ON BACK <br /> PARR 1'(ll M H <br /> Huier <br /> E3 <br /> Pick U tuo less N3tt1e�(optional-Address Label <br /> MLTR <br /> Address 1053 BOARD <br /> _. WALK DR. <br /> City, State,Zip STOCKTON, CA 95206 <br /> 0 <br /> �_�_ EE[_1 <br /> 209-962-Hauler's Business Phone $(i elude area code) } 4� IY� Ll <br /> Hauler Exemption(If applicable) <br /> Government ❑LEA Exempt <br /> Load Date (MM/DD/yy) Log Number <br /> _ LL <br /> Y, Agriculture ElCommon Carrier/ <br /> BackHaul <br /> . T t Indicate(if applicable)F] in Transit <br /> I, ILicense Plate Number _ _State Decal Number <br /> ❑Confidentiali Claim: The information provided in Part I and Part II of:tfffs form should be considered confidential,proprietary,andfor trade secret. In <br /> accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information, I request ihatOWMB Contact <br /> me at the address andfelephone 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 thaNalsification 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,por violation or,administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> Driver's Name(print) ' Dtfti`s ignature Date <br /> � s r ul i✓r tt�►t. ESEN >x i"��► Ir f I ATei °- <br /> '�HE,Ta E � ,jCK n . at t i3r l r=i ._ <br /> - <br /> . r <br /> Business Name Facility's Business Phone (include alrea code) <br /> Number&Street Address <br /> _ ❑Address Same As Hauler <br /> ❑Change Of Address <br /> L. <br /> :City Sta Ip C de <br /> L Tire Types and Amoiint Intended Use <br /> ij (3 Passenger Ove ze ❑Retread/Reuse <br /> t _ JJJ rr_.�. _ T <br /> Tire Program ID Site Suffix r I f { <br /> �__ __ �.J Recycle <br /> Load Yypt t ,;t tti. n [❑Truck ❑ ee <br /> �. lrh�ile l ir" t of lit �', ,: �� t— T <br /> _ ❑ Fuel . <br /> \li I!ni t dPr'S i 1 fru ;i' ❑Disposal/Landfill <br /> _ <br /> Y _1_1 ETI <br /> Load;l mount <br /> Comment A ea ' <br /> rj j � • <br /> ❑Confidentiality.Claim: Tfie information provided in Part"i and Part If of this form should be considered confidential,proprietary,and/or trade secret. <br /> In accordance with Title 14,CCIA,Section 17041-et:�eq,should any member of the public request disclosure of this information, I request that CIWMB <br /> contact me at the address an elephgne:number above. <br /> -. ._ <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 nalties 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. f <br />