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Integra te oard CA Uniform ste and Used Tire Manif ct CallOBox1259,teacra Sacramento, agornenl 1259 PO Box 1259, Sacramento,CA 85812-1259 E X A MI P Ll 1 2131 Manifest Number State Of Cattlomle CIWM9-647(0=3) INSTRUCTIONS ON BACK M9 - 11, 04575 PART I: TO BE COMPLETED BY TIRE HAULER (please print) Pick Up El Import from WILSON WAY TIRE CO. INC (If outside California State/Country) 221 N.MWN WAY STOCKTON, CALIF 95205 ❑Delivery i ❑ Export to (If outside California State/Count ry) Haulers Business Phone 0 Z/(include area code) / 1 � � _ f � 3' B � —] �' Hauler Exemption (if applicable) ElGovemment El LEA Exempt Lod Date (MM/DD/YY) Log Number ❑Agriculture [I Common Carrier/ 9 � ^ 7 7 C 4 7 Back Haul Y Indicate(if applicable)❑In Transit LI nse Plate Number State Decal Number C nfidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary, and/or trade secret. n a rd ance 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 t the address and telephone number above. I certi y that under penalty of perjury undor the laws of the State of California that the information provl above is true and correct. In addition,I am aware that falsification of this info anon ay result in suspension,revocation,or denial of ronewaf of the Waste Tire Hauler R ration pursuant to Public Resources Code section 42960 and may result in civil pen ie to$25,000 per day,per violation or administrative penalties up to$5,000 per vidati er day as described in Public Resources Code section 42962. - /0 —0� i Dr er's Name(print) r er's SJjWture Date P T II: TO BE COMPLETED BY REPRESENTATIVE OF RE DEALER OR WASTE TIRE GENERATOR OR END-USE F ILITY (please print)-USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DRQPPED OFF. Business Name v Facility's Business Phone (include area code) Number&Strtl Address ❑Address Same s Hauler, / C 6 ❑ Change Of Address City State Zip Code Tire Types and Amounts Intended Use ❑Passenger ❑Oversize ❑ Retread/Rouse Tir Program ID Site Suffix E]Recycle d Type(check only one) XTruck ❑Other hole The Count ❑Weight in Pounds c ElFuel iii'olume Cubic Yardsht In Tons C ❑Weight � ❑Dlsposal/Landfill Load Amount C Comment Area Anfidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. ntordance with Title 14,CCR,Section 17041 et.seq,should any member a 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 awe of the State of California that t i oration provided abo is true and correct In addition,I am aware that falsification of this info nation y result in civil pen ' up to 5 per day,per vidat or i ' trative penalties up t 000 per viol Ion r day as described in Public Resources Code secti , 4 Ae IelentatIve Name rinr> senta:tW1W.Ci:4b.ca.govfrires/ (gnDate 32876 Toll Free 1-866- 96- 600 / White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Fad lity Copy Yellow:Hauter Copy