COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

mw A Uniform Waste and Used Tire Manifest CalltomialntegratedWasteMailagementBoard PO Box 1259 Sacramento CA.95812-1259VU-M! 1 ■ EU A MLTE1. 2 3 1U.1-1.1211 - 11 r state m California ECManifestNumber 1 41 83-4 5.ciwrae sa'rtnzlosl INSTRUCTIONS ON BACK PARI 1: TO BE COMP1�'i` Pick U 9.- Hacri+ri (optional.-Address Label) I_l 1111pol f fl(,)n Business Namel {lf ti� I>tdn r !Uiorni' Address MLTR ,.; ,� 1053 BOARDWALK DR*Delivery VIII City: State. Zip j STOCKTON; CA 95206 t ;Ili)in;�T Hauler's Business Phone 2 �- (include area code) Hauler Exemption-(if applicable) ❑Government❑LEA Exempt Load_ late (MM/DD/YY) Log Number ❑Agriculture . ❑Common Carrier/ Back Haul i - . ejIndicate(if applicable)❑In Transit License Plate Number State Decal Number ❑Confidentiality Claim: The information provided iiaAart t 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 C1WMB contact: me at the address and telephone number above. I certify that under penalty of perjury under the laws of the State of Califomia that the information provided above is true and correct. In addition,I am aware that falsitication 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 42962, ,4 er's Name Signature r first . :_ � tE - . ''j''�g n` � 1Ad�.y-1'#:��"If3E.�ar��tVl�f�!°�.l+:�f-t t.,E� dna jt.t V.,taiJffSir �!rIF11) irl T.;'-2c' 4•;�L FN�1' ..::,i, :: ;43�� !2! r- +F RJ)RO��PED ��i"�� �-� --- (trptionat-Andress Business Name _ Facility's Business Phone (include area code) L_1_1—_ _I Number.&,Street Address. f ❑Address Same As Hauler L_1�_J.__J —_l__l__i—_.:1 I--t._ i Y__ ! __I_ ;i__1_—_J i._"I----.__! I___L....-_J�1.._v1� Change 0f Address City _ _ __ State _ Zip Code Tire Types and Amounts Intendedfpse ❑ Passenger ❑Oversize t3etreatiReuse;' Tire Program_1D. Site Suffix r []Recycle F __._t_I Truck. ❑Other iol 1 ire t,onml ooh! lil i-,dr— —� -- ElFue 1 1 �',,Lun�,. ti_tl1)iC't f1s.}• 1 � 1+Vri�llt#.i; 7, T � �—�� Ll__.-� __ �_ ❑ Disposal/Landfill c�ac1 rtlptrl#_: Comment Area []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;GIWMB contact me at the address and.telephone number above. I certify that under penalty of perjury under the laws of the State of California that tie information provided above is true and correct.In addition,I�t 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 descriied in Public sesources Code section 42962. - a e'