Laserfiche WebLink
CA Uniform Ste and Used Tire Manifest California Integrated Waste Management Board <br /> PO Box 1259, Sacramento,CA 95012-1259 <br /> •` e� <br /> E X A M P L E 2 3 Manifest Number <br /> CState rIfIM -647(omta INSTRUCTIONS ON BACK M V - 1 2 0 3 0 7 7 <br /> CIWMB-047(031031 <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> Pick Up <br /> ❑ Import from <br /> (If outside California State/Country) y 4q1114_%N A,�f <br /> ❑ Delivery <br /> ❑Export to <br /> (If outside California State/Country) Hauler's Business Phone Q �/ <br /> (Include area code) ( Z Q 7 ) <br /> � � _ / � Hauler Exemption (if applicable) <br /> ,(� ❑Government ❑ LEA Exempt <br /> Load Date (MM/DDNY) Log Number <br /> ❑Agriculture El Common Carrier/ <br /> //' Ste— Back Haul <br /> O © — �" / Indicate(if applicable)❑ In Transit <br /> License Plate Number State Decal Number <br /> confidentiality 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 penal 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 resul suspension,revocation,or deni ewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil <br /> ' <br /> penalties up to$25 0 per d per ,on orstrabv sup to$5,000 per violation pet day a din blit 'urces Code section 42962. <br /> Driver's Name(print) Driv is Sign&Gre 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 /> 41 <br /> Business Name Facility'?usine"ss Phone (include area code) <br /> Number&Street Address <br /> Address Same As Hauler <br /> 40 <br /> �3 ❑Change Of Address } <br /> City State ZiTp Code <br /> Tire Types and Amounts `Inttended Use <br /> Tire Program ID Site Suffix ❑ R <br /> — <br /> Passenger ❑Oversize l Retread/Reuse <br /> /'�\ <br /> ❑ Recycle <br /> �Lc Type(check only one) Truck ❑Other <br /> hole Tire Count []Weight in Pounds � Fuel <br /> lume Cubic Yards ❑Weight In Tons . 02 <br /> XDlsposal/Landflll <br /> a <br /> Load Amount Q O Comment Area <br /> *onfldentiality 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 civil penalties up to$25,000 per day,per violation or administrative penalties u to$5 per violation per day as described in Public Resources Code <br /> section X7. <br /> 1�yw /,/, ;?,c c3 <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 Dealer/Generator/End-Use Facility Copy Yellow,Hauler Copy <br />