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.... CA Uniform ate and Used Tire Manif t California Integrated Waste Management Board PO Box 1259, Sacramento,CA 95612-1259 E X A M P L 23 1 - Manifest Number State of California CIWM8.647(D3/03) INSTRUCTIONS ON BACK M 2 - 1 1 7 8 3 7 3 CIW M !PART I: TO BE COMPLETED BY TIRE HAULER (please print) Ick Up (./ lre4�_ 4W4 C7 ❑ Import from (If outside California State/Country) C Delivery I ❑ Export to Hauler's Business Phone 7 (if outside California State/Country) (include area code) ( 16 IHauler Exemption (If applicable) L / / O 5 _ I 0 ❑Government ❑ LEA Exempt Load Date (MM/DD/YY) Log Number ❑Agriculture ❑Common Carried (� �J �7 (' Back Haul �!— ,� Q / ( , � 403 �� J Indicate(if applicable)❑ In Transit L4cense Plate Numb State/ Decal Number Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret.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 contact me at the address and telephone number above. I certify that under penalty of ry under 1 laws of the State of California that the information p d above is true and correct. In addition,I am aware that falsification of this Information may result in au ension,revoca' ,or denial of renewal of the Waste Tire He eg tion pursuant to Public Resources Code section 42960 and may result in civil penalties up to 25,000 per d r vial or administrative penalties up to$5,000 per r day as described in Public Resources Code section 4 962. oc l o Driver's ame(print) Tiller's Signature Date (FART II: TO BE COMPLETED BY REPRESENTATIVE Ole TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY(please print)- USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED,OFF. Business Name /' Facility's Business Phone(include area code) r/ t� V0 fyv'?# c:�pF C_* Number&Street Address ❑Address Same As Hauler 4PI 50 IC C]Change Of Address r City State Zip Code Tire Types and Amounts Intended Use ❑Passenger ❑Oversize ❑Retread/Rouse Tire Program ID Site Suffix g ra ❑Recycle i toad Typo(check only one) /Truck ❑Other Fuel Whole Tire Count ❑Weight in Pounds ❑ Volume Cubic Yards ❑Weight In Tons C • / ❑Disposal/Landfill Load Amount O Comment Area mconfidentiality Claim:The information provided In Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. M 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 me at the address and telephone number above. 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 civil penalties up to$25,000 per day,per violation or administrative penalties up to$5)POO per violation per day as described in Pudic Resources Code section 42962. 1-}/ h / t CLQ ��- }'IJ? Z Representative Name(print) Representative's Signature Date 32876 ■ Toll Free 1-866-896-0600 / www.Ciwmb.ca.gov/Tires/ White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow.Hauler Copy