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CA Uniform ante and Used Tire Ma if t CaliforniaPCntegrated Waste Management Board <br /> I PO Box 1259, Sacramento,CA 95812-1259 <br /> kE X A M P ILI,, 1 2 3 ��AA Manifest Number <br /> Stets of Callfomle <br /> CIYYMB-6I7(03+43) INSTRUCTIONS ON BACK M 3 - 1 1 7 8 3 7 4 <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> I <br /> ❑ Pick Up <br /> El Import from <br /> (If outside California State/Couniry) <br /> very 4:31�rr`�_ <br /> ❑ Export to <br /> (If outside California State/Country) Haulers'u 6 Business Phone <br /> (include area code) /'Y � <br /> i <br /> l Q I kyr Hauler Exemption (if applicable) <br /> d ❑Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number ❑Agriculture ❑Common Carrier/ <br /> j Back Haul <br /> 10 7 a 3 �/ Indicate(if applicable)❑In Transit <br /> Cense Plate Number State Decal Number <br /> Onfidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential,proprietary,and/or trade secret. In <br /> %67cordance 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 <br /> I certify that under penalty of perjury under the aws of th tate of California that the information provided above is true and correct. In addition,I am aware that falsification of this <br /> information may re ult in suspension,revocafi or al of renewal of the Waste Tire Hauler Registratio rsuant to Public Resources Code section 42960 and may result In civil <br /> penalties up to$ 0 per day,per violation o inisirative penalties up to$5,000 per violation ascribed in Public Resources Code section 429651. <br /> Driver's Name(print) Drive nature Da e <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF T114E 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 /> - <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> ddress Same As Hauler <br /> ❑Change Of Address <br /> City State Zip Code <br /> l — Tire Types and Amounts Intended Use <br /> Oy )J- — f� ❑Passenger ❑Oversize ❑Retread/Reuse <br /> Tire Program ID Site Suffix �y , <br /> �a ❑ Recycle <br /> ad Type(check only one) ❑Truck ❑Other <br /> El Fuel <br /> Whole Tire Count ❑Weight in Pounds C <br /> Volume Cubic Yards ❑Weight in Tons G .g a ❑Disposal/Landfill <br /> Load Amount O Comment Area <br /> fidentiality Claim: The information provided In Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. <br /> _3accordance with Title 14,CCR,Section 17041 elli 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 /> 1 certify that under penalty of pequry under the laws of the State of California that the int all provided above is true and correct.In addition,I am aware that falsification of this <br /> Information may result in civil penalties up to$25,000 per day,per violation or administ we penalties up to$U00 per v oration per day as described in Public Resources Code <br /> section 4292. - <br /> fi�V A aL r &,"L 'A <br /> Representative Name(print) Represente's Signature Date 32876 <br /> ■ <br /> Toll Fr1-866-896-06008 <br /> White: py Pink: a ator it <br /> / tlww.ciwmb.ca.gov/T*Ires/ <br />