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California Integrated Waste Management Board . _ CA Uniform Waste and Used Tire Manifest PO Box 1259,,Sacramento,CA 9.58 12 ■ . EXAMPLE 1. 231 MM Manifest Number State of California INSTRUCTIONS ON BACK i 'v! 4 " O ctwrtn 6a%(03!03) - - - - --� PART I - G .' HatlILi _ptioaa; Address Label) PiCk Up (o.l iltyx3lt tlorlt Business Name i , - Address 1053► er} '" , alk Dr- City, State, :Z;p Stockton,CA 95M I J Eyxi)�ri tri – (2 } Hauler's Business Phone ` f ! TJ (include area code) I LEL] 1 } Hauler Exemption-(if applicable) r [TA �_ _ �'7V� Government LEA'Exem t r p J Load Ltate (MWDD/W') p Log Number _ w t agriculture .,)�Common Carder/ j — E-1-71. Back.Haul / ,.' Indicate(if applicable)[I in Transit C_ �._ . License Plate Number State Decat Number pConfidentiality Claim:The information provided in Part I and Part II of this farm 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 CIWMB contact me at the address and'telephone nuttlber above. 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 arfiaware 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$5,0130 per violation per day as described in Public Resources Code section 42962. Driver's 3 lIe(print) Dign C1tit river's ature tri` 14'! _ 'dI oi €-.N J'JIS1 . ,, ,i ACT01 i LOCATION NUG QWPOi? 9 t (optional Address L.aJ . LE Business Narne Facility's Business Phone(include area code) - L_s.,c L_.�I_ Number&.Street Address ❑Address Same As Hauler ,' El Chang Of Address L.__.I ._.i_�._L—k - .L___k 1._.__1__.1_._L__ __1__ t_ 1. �y.._ J_.__J I—Id 1__<.1_... t.`�1_ City _ __ _ _State Zip Code_- LI r Tire Types and Amountsl� _ Intended Use E_�_ II-TI 1t_�� Passenger ❑Oversize _._ T ❑Retread/Reuse _. _ .. Tire Grogram ID Site Suffix ; ! I Recycle -1 T, Load Type (cii rk riri)�+ " "' [i Truck ❑Other ❑Fuel. n ,.0 cunt r:Y01 l- __.i ��—� QDisposal/Landfill E1.l_ _ �_ l_ god ArniquA-t�.,,I �Yr�,,;. � Comment Area W_-. -- - - - pConfidentiality 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 reques4gclo5ure of this infonnation,I request that CIWMB 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 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,pqr violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962.