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Friday,January 07,200510:08 AM D Montecino 707449-8943 p•02 <br /> i`Fk�n...-•.. .•,... �•1�•I,.�V.L.,w'- - �. s � 'pis-- -w+.f-.�_aw�...w.i-kn-� <br /> Calitomia Integrated Waste Management Board I <br /> CA Uniform Waste and, Used Tire Manifest . .. POBQx-1259, Sacramento,CA 95812-1259 I <br /> ■ E X A Mj P j L 1 E! 1 j 2 j 3 tt Manifest Number ■ <br /> Crate 0 Cehrcrnia INSTRUCTIONS ON BACK M 5 - 1 3 6 7 813 <br /> �!. <br /> CIWM&a/7(03rW) _ <br /> f _ ,-- .- 4►�yam; "" --- <br /> ! Hauler �(optianar d;irsss Labeli <br /> Rusinthss Name! IMNGF00T <br /> Address COMMERCIAL TIRE <br /> 405 GANDY DANCER DR. <br /> iCity,State,zip { TRACY, CA 95377 �+ ! <br /> - _ <br /> ! <br /> Hakiler's Business Phe <br /> riclude area code) <br /> ^ i --[k <br /> �_ L1J <br /> l <br /> I I <br /> Hauler Exemption tit applicable) <br /> a ❑ P <br /> r Government LEA Exerri t <br /> Load Date(MWDDNY) Log Number ❑Agriculture ❑common CiIWer/ <br /> - D -� Back Haul i <br /> 0 �" r 9 V--L <br /> J indicate(if applicable)❑In Transit <br /> Lq k-1 <br /> License Plate Number State Decal Number <br /> f <br /> ❑Confidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret.In <br /> accordance with Tifle 14,CCR,Section 17041 el.seq,should any member of the public request disclosure of this information,I request that CIWMB contact <br /> me at the address and telephone number above. Y4, <br /> I certify that under penalty of perl'ury under the laws of the State of California that the information provided above is trice and correct. In addition,I am aware that falsification of this <br /> ! Imfoenrma may result In suspension,(evocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may resultin civil <br /> t palti 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. <br /> f I <br /> I: er s Name r t Drivers Signature Date <br /> ! RitltAtl W� Mp <br /> -. 3AT <br /> ? <br /> I <br /> Addres ,abet) -- — 1 <br /> Business Naro6 cility's usiness Phone(include area code) ! <br /> Number&Street Address I I <br /> ` 11-6-��,`J` �� ` ! i Add ress Some As Hauler <br /> L_� 9I Cl ❑ChanpeOFAddress <br /> City _ State-- Zip Code -- - _ <br /> 1� Tire Types and Amounts Intended Use <br /> I J J 371 1 <br /> L, O (� ❑Passenger ❑Ovaisize , ❑Retread/Reuse I <br /> Tire Program ID Site Suffix <br /> i ! ❑Recycle <br /> []Truck ❑Other <br /> Fuel <br /> II <br /> r"T ❑ I <br /> ❑Disposal/Landfill ! <br /> Comment Area l <br /> OBOdinfidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret, <br /> In accordance with Title 14,CCR,Section 17 . 1 et.seq,should any member of the public request disclosure of this information,I request that CIWMB <br /> contact me at the address and telephber above. <br /> I certify that under penalty of perjury r I s of the State of Caldomia that the information prov ve is Irue and correct.In addition,I am aware that taisification of this <br /> information may result in civil pe p'to 000 per day,per violatl tntstrat ve pe be p 55.000 p r violation per day as described in ublic Resources Code <br /> y /, �, 1, /r%7 ��/ �� � ✓ )t� � �l f <br /> Repi-esont ive ame(oriel) <-`.--Rf�presentafive's Signature Date 32876 i <br /> Toll Free 1-866-896-0600 / www.Ciwmb.ca.govfrires/ r - ■ <br /> White:CIWMB Copy Pink.Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy LLL] <br /> FOP.MNO,M-104799-CMI un inm 2229s?sSa5 ' <br />