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ed <br /> CA Unifor aste and Used Tire Mani { CaliforniaBox 1tegr, Sacramento, <br /> to,CA 9 Management Board <br /> PO Box 1259, Sacremento,CA 95812-7259 <br /> E X A M P L 1 2 3 Manifest Number <br /> State of California <br /> M5 - 1104555 <br /> CIWMB-847(03J03) INSTRUCTIONS ON BACK <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> ❑ Pick Up <br /> ❑ Import from WILSON WAY TIRE CO. INC <br /> (If outside California State/Country) 221 N.WILSON WAY <br /> {Delivery STOCKTON, CALIF 95205 <br /> +� ❑Export%) <br /> (If outside California State/Country) Haulers Business Phone <br /> (include area code) <br /> / L4 _ ) v S_ 7 Hauler Exemption (if applicable) <br /> l ` !� El Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number E]Agriculture ❑Common Carrier/ <br /> G $o n 7 C /t 7 T ❑D — 6 I Back <br /> Haul <br /> / i <br /> indicate(if applicable) n Transit <br /> LIense <br /> Plate Number State Decal Number <br /> onfidentlality 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 prov d above is true and correct. In addition,I am aware that falsification of this <br /> Informa11 may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler R tration pursuant to Public Resources Code section 42960 and may result in civil <br /> penalties p to$25,000 per day,per violation or administrative penalties up to$5,000 per vielad per day as described in Public Resources Code section 42962. <br /> 61-�klc41 1/- 6 - dr <br /> 15river's Name(print) grier's Wature 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. j <br /> 01 /.;,4^j "E �Z-14W C"?, 0 � ) 4 U/S - -,7 ,2 <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> Q� ❑Address Same s Hauler <br /> ❑Change Of Address <br /> City State Zip Code <br /> / r Q Tire Types and Amounts Intended Use <br /> 1 a' Q 9 7 / — D / ❑Passenger ❑Oversize ❑ Retread/Reuse <br /> Tire Program ID Site Suffix W ❑Recycle <br /> to <br /> d Type(check only one) 2 X7ruck ❑Other ❑Fuel <br /> Whole Tire Count []Weight In Pounds I cc <br /> c <br /> Volume Cubic Yards Weight in Tons L l <br /> ❑ ❑ 9 ;: � ❑Disposal/Landfill <br /> Load Amount CL <br /> C Comment Area <br /> Co <br /> nfidentlality Claim:The information provided In Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. <br /> n cordance 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 lays of the State of California that the int ation provided above is true and correct.In addition,I am aware that falsificatlon of this <br /> information may sud In civil penalties up to$25,000 per day,per vtoledon or admin retive penaldes up to$5,000 per violation per day as described In Public Resources Code <br /> section 4286 <br /> Representative Name(print) Re rase ative'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 />