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v■—■ v■u*P771 v■ ■■■ ■rugae G■■M v�7E—iM ■ ■■r. l*■Q■�■■G�a PO Box 1259, Sacramento,CA 95812-1259 O � EIXIA M P L E j 1 1 2 Manifest Number State o-647(10/03) INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE M 7 - 2 .0 8 4 1 13 CIWMB-647(10/03) By signing this CA Uniform Waste and Used Tire Manifest.the signer(s)requests that the information provided on this form will oe 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 aad telephone n,imber provided on this manifest, .RT If TO BE COMPLETED BY TIRE HAULER PLEASE PRINT f1RMLY Hauler f fs Pd+�} � ' !, fi �� R ' ;' Pick Up Delivery Business Name 7" 06� � ' C . Please complete if outside California Address City, State. Zip ❑Import/Export Hauler's Business Phone State/Country (include area code) Load Date (MKDDiYY) Log Number Hauler Exemption(if applicable) �_. ❑ Government ❑ LEA Exempt ❑ Agriculture ❑ Common Carrier/ License Plate Number State Decal Number Back Haul Indicate (if applicable) ,I ! 4 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$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. t Driver's Name(print) ,1giver's Signature Date RT II; TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. F AOTUAL LOCAT1ON WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. PLEASE PR14T FIRMLY, Business Name Facility's Business Phone (include area code) 5A /V 0'0 r=) —Tr, GY lei .a Number & Street Addr6ss City J State Zip Code FlAddress Same As Hauler S) Change Of Address Tire Program ID Site Suffix Load Type (check only one) Load Amount Whole Tire Count Weight in Pounds Volume Cubic Yards[ in Tons whole Numbers only Decimal for Whole Tire Count c Passenger Amount Oversize Amount Intended Use ❑ Retread/Reuse ❑ Recycle ❑ Fuel ❑ Disposal/Landfill R1- Comment Area GTruck Amount Other Amount Q * ■ d certif that Y r penalty f Pru under the laws of the State of Cgiuomta.that the information pr ided above is true and correct.In addition,I am aware that falsification of this Y p Y P 1 3 informa' may result in pjv , en'alties up to$25,000 per day,,per'violation cr„ad✓aiinistrat a ies,up to$5,000 per violation per day as descrii ed in P lic Resources Code s_ti 42962 rseMesertaafive Name(print) Represerita#five's Signature Date 2s1a7 Toll Free 1-8fi6- 896-06.00 / www.ciwmb.ca.gov/Tires/ �J White:CIWMB Copy Pink:Tire Dealer/Generator,'End-Use Facility Copy Yellow:Hauler Copy t 1.Remove top stub 2. Fold in half at fold line 3. Remove adhesive strip 4. Adhere remaining stub ren Pliny r3cnnnliC rWIQ CTI IR r_ o;e. s- -8 ;s:z