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' a ~ California Integrated Waste Management Board CA Uniform Waste and Used Tire Manifest PO Box 1259, Sacramento,CA 95812-1259 . - ,�� XAMR' LE -23 -� I Manifest Number 85 State of California L 4 $ �, e r.te.�;:f,1iu:va:,1 INSTRUCTIONS ON BACK tt__ PART 1: YO I�14 ruC�►wl��t�'� .`. . .� Address La Pick U; Har. (optional'-Address bel Business Name uleMLTIt I i jr ipott irort� _ 1053 Boardwalk Dr. (If o t hide t nIitorrIi,,I S Address stockton,CA 95206 r - Cit p Deliver209 9829408 _.I er y, State, Zi ( > - I. 1 Export to Hauler's Business Phone -- (include area code) Hauler Exemption-(if applicable) 1:.... __ / / �� f. ' ■ - f `Y; Government (]LEA Exempt ( w� ❑ MMfoonr Load to Log Number ( Y) __ ❑Agriculture -(]Common Carrier/ t a rt L . Back Haul *' Indicate(it applicable)n In Transit _ 1 License Plate Number __ State Decal Number ^_ pCdnfidentiality Claire: The information provided, Jind0and Part 11 of this form'should be considered confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.sgq,should any member of the public'request disclosure of this information,I request that CIWMB contact me at the address and telephone numi er`aboVe l:certffy that under pehalty of perjury under the laws of'the State of California that the information provided above is true and correct. in addition,Ian)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 result in civil penalties up to$25,000 per day,per violation or administrative p allies up to$5,000 per violation per day as described in Public Resources 7,.ction 429662.. Driver's Name�pnnt) it Driver's Si nate, re ffiD i 1L G A lc h 1►: l its y l i i I _t oIJF1f�r;�l t�i (ophOn•t-Ad ress Label) :--• I - - - - - - — ` Business'Name f=acility's Business Phone(include area code) l - I 1 t I I I l .�..__...J N tuber&Street Ad"s j E]Address Same As Hauler l •. ❑Change Of Address .J�.f L+ � f '-.-:1 .!__I�.J City State Zip Code' - — - T're Types and Amounts Intended Use Lc � > '� Passenger ❑Oversi_ 777��1 LL _ _ ❑ Retrea euse ire Program ID Site'suffix T-1-1 .`� r y A. �1 ,,{ L =1 1 `f' RecyGe uad'Type it 11(yc a ❑Truck ❑Other - El Fuel Y!pv l lir t`,n t 1 wilt tp; LEIL oll.m 1_.�.bl"i Y,11 d^ ( , Ih � 0 Disposal/Landfill _� C L-LI-_ ltoa Comment Area []Confidentiality Claim: The'information pro ed in Part I and Pa of thislorm should be considered confidential,propti Bary, fltl/or trad ecret. In accordance with Title 14,CCR,Section 17041 et: ,should any member of the public requesVisclosure of this information,I request that CIW contact meat the address and telephone number above. I certify that under penalty of perjury under the laws of the State of California that the informati0Q provided above is true and corcect.In addition,I am awake that falsification dl this information may result in civil penaltles up to$25,000 per day,per violationlor administrative peiyalties up to$5,000 per violation per day as described in Public Resources Code section 42962. '