Laserfiche WebLink
,�, California Integrated Waste Management Board <br /> ® ; CA Uniform Was and Used Tire Manife PO Box 1259, Sacfamenlo,CA 95812.1259 <br /> . EXAMPLE 2 3 Manifest Number <br /> State of California <br /> CIWM&647(03A3) INSTRUCTIONS ON BACK <br /> M 1 - 1 2031 30 <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> i❑ Phck Up 11 1 <br /> CJ.Importfrom i C ��.�il ` 75 yt P <br /> (if outside Califomia State/Country) <br /> - oeiivery <br /> ❑ Export to S�'C'C G� }(}y� <br /> Ha(ncluler's Business de) O 1 ( — <br /> (It outside California State/Country) `O <br /> include area code <br /> Hauler Exemption (if applicable) <br /> L ❑Government ❑ LEA Exempt <br /> Load Date(MWDD/YY) Log Number <br /> c / E]Agriculture ❑Common Carrier/ <br /> (0 8Back Haul <br /> OC Y4 63 v J i Indicate(if applicable)❑ In Transit <br /> License Plate Number State Decal Number <br /> *onfidentiality 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 California 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 violatio 9r day as described in Public Resources Code section 42962. <br /> Driver's Name(print) river's Signature Date <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE 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 /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> ❑Change Of Address <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> 9 7 " Q , [1 Passenger ❑Oversize ❑ Retread/Rouse <br /> Titre Program ID / Site Suffix ❑Recycle <br /> Oad Type(check only one) ck ❑Other <br /> Whole Tire Count Weight in Pounds tvc Fuel <br /> ❑Volume Cubic Yards ❑Weight in Tons Q eZ_ posal/Landfill <br /> Load Amount O Comment Area \ <br /> Confidentiality 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 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 evil 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 /> 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 Fad Illy Copy Yellow:Hauler Copy <br />