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' CA Uniform_ Waste and Used Tire Manifest CaGfomial1259,tSacrametoanagemenCBoard <br /> .•.. PO Sox 1259, Sacramento,CA 95872-1259` . <br /> .... T l <br /> •••• I TT] ( Manifest Number <br /> EXA.M P L E 1 2 3 <br /> '�M5 1598135 <br /> State of Cnittomfa <br /> r.rWMtl-64,(03103) INSTRUCTIONS ON BACK <br /> PART I: T <br /> I._.!,Pick lap, J <br /> Hauler, *(o�7uon al-Ac di-SS Label) _ <br /> t1ljJllrt' Su ainess Name{ MLTR COMPANY <br /> 1053 Boardwalk Dr. <br /> Address <br /> Stockton,CA 95206 <br /> e City. Stale, Zip (209).982-9409 <br /> _\port`jff _ <br /> Haulers Business Phone '� <br /> (include area code) FT__.-� <br /> Hauler Exemption (if applicable) <br /> ❑Govemment ❑LEA Exempt <br /> Load Date (MMrnonrY) Log'Number <br /> Agriculture <br /> 171 Common Carrier/ <br /> / Back Haul <br /> Indicate(if applicable)[3 In Transit <br /> License Plate Number _ State Decal Number <br /> C]Confidentialit Claim.The• <br /> y information provided in Part I and Part It of this form should be considered confidential,proprietary,and/or 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 that CIWMB contact <br /> me at the address and telephone number above. <br /> I certify that underrpenafty 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 /> intormation may result in suspension,revocation,or denial of renewal of the Waste-rire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil <br /> penalties up to$25,000 pet day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resournes Code section 42962. <br /> ! <br /> IL <br /> Diver's Name(print) - Driver's Signature Date <br /> ►W i't. rc►I t> v t r sun Lf � <br /> ("I I'i'i ;I.rl� �. tiA ,rl , a -O�� <br /> d f <br /> —. .r r 't <br /> 1 t.C y <br /> LL L( E>_ <br /> ff <br /> Business Name Facility's usirtessPhone (includearea code) <br /> _ ✓_J_.._�L.� _ <br /> NLimber Street.Add_ress <br /> ` - ❑Address Same As Hauler <br /> ,:~ { - CO ❑Change Of Address <br /> City _ _ _. tate -` �I V <br /> - Code <br /> Tire Types and Amounts Intended Use <br /> Passenger ❑Oversize ❑Retread/Reuse <br /> Ire Program l Site SuffixRecycle <br /> �In EL f I <br /> _ `�+ M <br /> { [� <br /> dti ❑Truck ❑Other <br /> Wlrclr 1rre(,onrtWeiynl in Pours ❑Fuel <br /> livhintr ('tfl�+c:Yat i d F +• []Disposal/Landfill <br /> _ <br /> ,LQad A - <br /> rricrunt' _ <br /> 1 l Comment Area — M <br /> � �..F^�eb kms'. �• <br /> []Confidentiality Claim: The information provided in Part I and P t 11 of this form should be considered confidential,proprietary,and/or trade 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 falsfficatign 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. `1� <br />