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i - -- HU box 1259. Sacramento,CA 95812-1259 E X A MI P I L E 1" 711]� Manifest Number ItaleClWM ,647'10/0 INSTRUCTIONS ON BACK uO NOT TAPE. STAPLE OR DUPLICATE M2 - 1950078 CIWMB-647(10/03) By signing this CA Uniform Waste and Used Tire Manifest,the signer(s)requests that the information provided on this torn will be considered confidential.proprietary and/or a trade secret. In accordance with Title 14,CCR,Section 17041 et seq.,if a request is made for disclosure of this information,the CIWMB will contact the signer(s)of this form at the address and telephone number provided on this mani'est. ,RT 1:, TO BE COMPLETED BY TIRE HAULER PLEASE PRINT FIRMLY'" Ick Up Delivery Hauler Business Name J °"le Address Rte, ( �, - t 0- Please complete if outside California -~-' 'Import/Export City, State, Zip ❑?v 4-4- '. jib '✓' Hauler's Business Phone State/Country (include area code) Load Date (MM/DD/YY) Log Number Hauler Exemption(if applicable) ,-, ;2Government ElLEA Exempt + '� ❑ Agriculture A --? g ❑ Common Carrier/ License Plate Number State Decal Number Back,'Haul 9 o r.--• Indicate (if applicable) j C°� - J ( `" - �, ❑ In Transit ❑ Unregistered Hauler 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 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$25,0//00 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. AJ J � IS Name(print) ; i erts-Signs,ure` --bate 1T 11: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. E ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. PLEASE PRINT FIRMLY siness Name Facility's Business Phone (include area code) Bu f Number& Strelt Address t City State Zip Code ElAddress Same As Hauler ❑ Change Of Address Tire Program ID Site Suffix Load Tyj)e check only one) Load Amount _ e Tire Count ❑ Weight in Pounds Volume Cubic Yards Weight in Tons Whole Numbe-r S�only -- for Whole Tire Count Decirnal mal Passenger Amount Oversize Amount Intended Use w p ❑ Retread/Reuse ❑ Recycle ❑ Fuel ❑ Disposal/Landfill O • • Comment Area O Truck Amount Other Amount O O certify that under nalty_QI perjury and¢}r the laws of the State of California Ihat tZe information prgvide above is true and correct.In addition,I am aware that falsification of this gfarmation m es�11Y n civil penalties to 525,000 per day;'per violation or administrative penalties into$5,000,per violation per day as described in Public Resources Code sectio } II I` 'Re� lv a ame(print) I- -representative's Signature r Date 26187 Toll Free 1-866-896-0600 / www.Ciwmb.ca.gov/l'ires/ White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy l� - 1.Remove top stub 2. Fold in half at fold line_ ^3. Remove adhesive strip 4. Adhere remaining stub