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ent <br /> CA Uniform ste and Used Tire Manif t Cali O"Box IntegratedWaste <br /> to,CA 5812-1 Board <br /> PO Box 1259, Sacramento,CA 95612-1259 <br /> EX A M P L 112 3 a Manifest Number <br /> state of ca4fornte INSTRUCTIONS ON BACK M Z - 1 1 0 4 15 6 <br /> CIwMB-647(03!03) <br /> PART 1: TO BE COMPLETED.-$Y TIRE HAULER (please print) <br /> Pick Up US, <br /> j <br /> ❑ <br /> r7 t <br /> ElImport from 65.30 11, ` <br /> (If outside California State/Country) Sa�irjtjduw� v. <br /> Delivery <br /> ❑ Export to <br /> (If outside California State/Country) Ha(ier's Business Phone <br /> - 0 <br /> include area codedeJ / <br /> Hauler Exemption (if applicable) <br /> ❑Government ❑LEA Exempt <br /> Load Date (MM/DD/YY) Log Number ❑Agriculture ❑Common Carrier/ <br /> Back Haul <br /> l /� - [ Indicate(if applicable)❑ In Transit <br /> License Plate Number State Decal Number <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 Title 14,CCR,Section 17041 et.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. <br /> I certify that under penalty of perjury under the laws of the State of Callfomla that the Information provided above is true and correct. In addition,I am aware that falsification of this <br /> 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 <br /> 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. <br /> 4t°1tc>/ -. &Rz?e", s <br /> Driver's Name(print) Driver's Signature Date <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRL DEALER OR WASTE TIRE GENERATOR OR END-USE <br /> FACILITY(please print) - USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. <br /> ys71-Re, 19 <br /> Business Name Facility's Business Phone (include area code) <br /> 1/A7ow 4- 19V61 <br /> Number&Street Address <br /> f G ` ElAddress Same As Hauler <br /> hey/ 0/ ❑Change Of Address <br /> City w `7 State Zip Code <br /> Tire Types and Amounts Intended Use <br /> j) 0 - D ❑ Passenger ❑Oversize ❑Retread/Reuse <br /> Tire[Program ID Site Suffix <br /> ❑ Recycle <br /> to <br /> Load Type(check only one) ❑Truck ❑Other ❑Fuel <br /> n Whole Tire Count ❑Weight in Pounds Iro- <br /> n <br /> I <br /> ❑Volume Cubic Yards ❑Weight In Tons <br /> ; �O 7 EJDisposal/Landfillfl. <br /> Load Amount O Comment Area <br /> • � 7 <br /> ❑Confidentiality Claim:The information provided in Part I and Part 11 of this form should be considered confidential,proprietary,and/or trade secret. <br /> 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 <br /> contact me at the address and telephone number above. <br /> 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 <br /> information 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 <br /> section 42962. <br /> r <br /> Representative Name(print) - Representative's Signature Date 32876 <br /> ■ Toll Free 1-866-896-0600 / WWW.CiWMb.Ca.gov/Tires/ <br /> White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy <br />