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CA:Uniform Waste and Used Tire Manifest CalrOBoxfornia ntegr. Sacraated sento,Cte gem812.ent 1259 L � __ _ - PO Box 1259 3ecr-amento CA 95812.1259 ,■ Manifest Number g A_�M]P ,L ET =12531 , } st,i. of r-lilnnoa I INSTRUCTIONS ON BACK L M 98 32 – PAf1T h. TO BE- IffliAE, HAULER (pl Pick l! (ft 0ofiaf-Address tr WI). —� C.I lirti� if1.irC Address,Business Namel MLTR CON '- ' r 1053 Boardwh. )r. ( ; Delivery City, State, 7_Ip Stockton;CAV20b ILtilnt- t Lr- r— i siness Hauler's BuPhone (include area code) ) j bi- / Hauler Exemption`(if applicable) FI_-- t ❑Government LEA Exempt Load Date (MM/DDNY) tog Number L._-_ __-__� ❑Agriculture ❑Common Carrier/ _ +`.._.� i Back Haul ' � TIC- 14 , r ` 1 r ; Indicate(if applicable).[] In Transit ,J I___ __L_ J_. 1_� License Plate,N_umber_ _ State Decal Number ❑Confidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential proprietary,and/or ttade'secret.In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information,*1 request that CIWMB contact me at the address and telephone number above: - I certify that under penalty of perjury under the taws of the State of California that the information provided above is true and correct. In addition;I am 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 penalties up to$5,000 per violation per day as described in Public Resources Code section 92962. 0i INer's Name_ (print)_ Driver's.S"gnatud - -- -- ---------- ate ,+til:,,T ;1. To ty Itlll�L '#�"S 'R l ,.E0-.41k.MSl'F_.TIRE GENERATOR 1=,,a;Il_11'y' t{ It,t':r Iii " TIAL l.0T1✓# ?f f3tlii C?0F _,�ti.�r. f I : Business Name Facility's Business Phone (include area code) Number&Street Address t ) C]Address Same As Hauler J:_._J L—L=J L Change Of Address City A _t ____._,._______.__ State Zips Code-i— --- _ Tire Types and Amounts Intended Use t, /Passen er ❑oversize toAl � L1` .... i I I% 11 [�� g , 0 Fletread/Reuse — I Ld Tire Program ID Site Suffix _ _ Recycle - � [ Truc [ OtherLl Ty e �__.. . _. .� . _Fuel VolumCIINC ` Ird; Disposal/Landfill F—T T-71 � ELL-Vhoto Iiir Co Int 41 Fi LaatConmentAre X _ nfidentiali Claim:The information provided in Part I and Pati II of this form should be considered confidential,proprietary,i rh ilcrc trade secret. pCo ty In accordance with Title 14,GCR,Section 17041 et.seq,should any member of the public request disclosure of this information,I request that GIWMB contact me at the address and telephone number above. I certify that under penalty of periury 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 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 section 42962.