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California Integrated Waste Management Board <br /> CA Uniforn ' aste and Used Tire Mani t PO Box 1259, Sacramento,CA 95812.1259 <br /> E X A M P L t l 12 3 Manifest Number <br /> State of California INSTRUCTIONS ON BACK M9 - 1 <br /> a - 1 1 0 41 3 8 <br /> ctwUBfi47 tovoaf <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> Pick Up <br /> Import from 601ror u7Qy 7re Ca <br /> (If outside California State/Country) 9,21 , Q i FLJ,,i way <br /> ,.. i <br /> ❑ Delivery ocr_1614 /S ZC�S <br /> ❑Export to <br /> (If outside California State/Country) Hauler's Business Phone — <br /> (include area code) ( � Q � ) � 6,� 0 <br /> .,� _ ) �•� Hauler Exemption (if applicable)/ <br /> 1 C / ;2 //V 0 / 3 l V 3 �. Q ❑Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> ❑ Agriculture [I Common Carrier/ <br /> Back Haul <br /> Indicate(if applicable)❑in Transit <br /> L cense Plate Number ( ✓ State Decca umber ✓ l ` <br /> Aonfidentlality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary,andlor 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 /> 1 certify that under penalty of perjury under the laws of the State of Califomia 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 /> Driver's Name(print) Drlver'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 /> 0 1 5 _ S , <br /> Business Name Facility's Business Phone (include area code) <br /> Lill r C l� ria aNumber Street ess <br /> ❑Address same As Hauler <br /> ( 1 h C y 0 ca ❑Change Of Address <br /> ,ty/ V ( State Zip Code <br /> Tire Types and Amounts Intended Use <br /> ❑ Passenger ❑Oversize ❑Retread/Reuse <br /> Tire Program ID Site Suffix m <br /> m El Recycle <br /> Load Type(check only one) ❑Truck Other ❑Fuel <br /> ❑Whole Tire Count ❑Weight In Pounds <br /> Volume Cubic Yards Weight in Tons Z <br /> ❑ ❑ g � Q ❑Disposal/Landtlll <br /> Load Amount O Comment Area <br /> T i <br /> onfidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. <br /> rn 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 42%2. <br /> Representative Name(print) Representative's Signature Date 32876 <br /> ■ Toll Free 1-866-896-0600 / www.Ciwmb.ca.gov/'rires/ <br /> White:CIWMB Copy Pink:Tire Deater/Generator/End-Use Facility Copy Yellow:Hauler Copy <br />