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<br /> ■ CA Uniform Waste and Used Tire I anFfest California Integrated Waste Managto,.PA mont-12$9
<br /> PO BoX.1259, Sacr$rrenta CA 95812 1259
<br /> t 1x1 IMS P I -1112131 Manifeo.Ni�mbk. .
<br /> stab of Caafornia ��!! QQ 7 Q n
<br /> cnvraa.sa7immy INSTRUC.TIO•NS ON BACK JYt.Q' Z l �i '3 '
<br /> {opt)oal-A' ss'C )
<br /> . :.77 �-
<br /> Address' 3�3 ; �� ,
<br /> City, State;Zio
<br /> Hauler's Business Phone• I
<br /> -- (inciude.area code) f I'L+ '• .; Jct ` . f J.•�(� lk-t
<br /> f (� Hauler Exoknption(i(applicable)
<br /> Go�rornMont L'EA ExeIm t
<br /> Load Date(mmA)oNy) , Log Number
<br /> — I - Alir►culttare,•::•O Commdn Cartier/
<br /> Back Haul
<br /> lntlk=W(A ap.0j; le)O In Transit
<br /> L•ibanse late umber take Decal Num6ec,
<br /> OCOnfident(alfty.Claim:The information provided in Part I and Part II of this form should be considered tAnfltlential,proprietary andlor trade secret.In '
<br /> accordance-vtet�i Ttlp 14,.CcG- SectO;j,041 et.seq,should anv member of the public regliesi dlscfosur0 t dlt{S Infafi •J ttst tJ►a;9fWtiOB'cant 4
<br /> the.avaat'P7V 'tef�jhhEkle nettt"berat�quQ:. .. . -.. ', ::. ..,Y } .�;.",5. ° �y?sa1 ; .ic 1�•t•" 'r•:s��9'%r,SN`..
<br /> i cert) that under
<br /> y ?malty Of perjury under the Laws of the$tate of CahfOmis thim"h?'17tforNr'�Ipq prpv'pe(a6oti•e iS�tGl�td'.00/lt�Et'Ih.EEId�IOn''68t�T wird iho!(�a�6 mt�w OYlrlis+f•".z';
<br /> information may result In suspentibrt•raveoatlon,or denial of renewal of the Waste Tire MauW Registratign pursuant to Puolie Resourm.Code section 4MO and may result ih Civil ,
<br /> penalties up to$4000 per day.wviofatlon or administrative penalties up to S6.000 per viotalionper y as tlescri yso
<br /> n Public Purces-OWe section 4298
<br /> -Driver's Name• tint Drifter`s Signature,' Date' 7
<br /> 701 ss Lane!) ---1 -: -
<br /> Business.Nartte FBCility's'Bosii>ieSs Phbne(include'area,code)` `
<br /> J`
<br /> .. 1 ! 7 V r0 ?W:
<br /> - i .1( t _ 1 t_ f. . .� f t 1 t r t I. f •1, t. t •t .l.
<br /> Number do StrM Addreas :- - -- —
<br /> ,I� �/•s ,r �/{� / �}AddraswSam As Hauler.
<br /> 1 ` 0 t�^ob OCAddrd is
<br /> City - - State Zip Code
<br /> , lr - Tire Types.and Amounts Intended Use
<br /> ado 3 �` 0 Passenger J]O"Isize , AetregdlFieuse�
<br /> Tire Program 1 Site Suffix
<br /> ;0 This Fuel.
<br /> ;�, -{: �' � :�:: '•�•.,: ;,1:,",'Q Qe4PosaNl.2Rdfill
<br /> .;�,. 'i7..3'%`�'�ts?'%�.ir�;=t•:�•t:>.' ::.'Ti�'f'i:"''`�';.j�;s.:.a.... .�-..Isi.'.�:',fa%::,. yp�r,•:� �;.�::�`•,.
<br /> .. -r..�.:. '.��(1'.�f'}t:�.'. :r•c::t:i e•t r:.;H.r:,yr.�.._S fxU' �4:r;..,._.'t.".,:
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<br /> MonMentiatity Claim:The information provided in Part I and Part ll of this form should be.considoitod.00ntidoMsat..proprietary, dndloeivadwawett
<br /> In aceordatuo With Tlpe 14,CCR,Section t7o4Z et.seq,Snotlld any member of the public request disc re of this Information,I request that CIM
<br /> contact me;at the t Wnpss,arxitelophone number above.
<br /> I ow*1flatunderponalty of octiury under the laws of the State of Californle that Vje !or tion p ap is _ and correct in addition,t a m aware tnat(�frc awn of this '
<br /> infmmattien may resuk in"p0nallies up to S25,000I�er.day,per yigledoo or. ve permRiaa � viol oon per Omy ae described in iC ReequrOgs Cotte
<br /> . .
<br /> eectiOn 62,f9$2. '' f/, \ _
<br /> R tfi8er►tativ NafM(print f A sentativ s 'nature . to '
<br /> � � 32876'.
<br /> Toll Free 1-866-896-0600/ www.ciwmb.ca.gov/Tires/
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