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y California Integrated Waste Management Board _A CA Uniform Waste and Used Tire Manifest Po Box 1259, Sacramento,CA 95812-1259 ■ Manifest NumyA�berEX MP L E 12 3 StafP.of Caro 1lifornia I M• 1 ' $,�4 5 ( - cmVrr.1P e r� rae, INSTRUCTIONS ON BACK V�J ART I- 1 0 R (Please )art IPick Upr, �(tJ�Prrltt�31-�tr:fdr :as Label)µ _L1Sif1C5S N�ETte Q linport from MLTR iif ,Tu'i dciress, _ 1053130ARDWALK DR. } Deliver t!ity. State, zip STOCKTON, CA 95206 2}0 9-982-9408_.�.h___. f 1_utltil1-- _ _ Haulers Business Phone TTTI (include area code) �rj _` Hauler Exemption lir applicable) ❑Government El LEA Exempt Load DaW(MM/DD/YY) Log Number Agriculture ❑Common Carrier! Back Haul. . .-.__ ._ _C_L�� _ir f __.{ G Indicate(if applicable)[f In Transit 1l License Plate Number State Decal Number pConfidentiality Crim.The information provided in Part I and Part 11 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',Vrequest that CIWMB contact me M the address and telephone number above. I certify that under penafty of perl'ury 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 suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 4.2960 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. DrNer's Name(print) river s Signature Date Ti. i" I C}itiPaf I" � � � w' t�1t � 51c7r"' total , nrft_Ir� i T41 CATION THE �rjEt lr�� c�t�l�t � �-) _ AJ M,-ss Labei) 7Jj -1- Business Name Facility's Business Phone (include area code) l_.____.L-_L___L-_�f_.-_f_.._l._...L^L.__...L_.._..t_.._�M;,„,.,;.d��'d-�«.�1•-;y,_.t. __.1:_�_�1�._._L_, 1_ 1 I _J__._.J Number&Street Address --� ,✓ ❑Address Same As Hauler e. ! ❑Change Of Address City ___ ___ . State/ Zip Code__ �Y - -- - Tire Types and Amounts intended Use � . :� (_ �. Passenger _.._ ❑Qverstze , ( ❑ Retread/Reuse Tie Program ID Site Suffix f �t ..._._ �. �___:�. w .fir sr_�_�_.._-._L.__��_...__� -� �.._�.__�..__�_.��.�� Recycle Luta TyWe (,heck ❑Truck ❑Other El �Vi aii� I rr t r iuN N�s)'tt nl F'C3 r " �. _ _ _ 7, [ .F VUeair.;lit a � �. �.. �"�� _....� .— -.:...__� _��_ � � �� Disposal/Landfill Load A outlt Comment Area ElConfidentiality 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 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 civii_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.