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CA Uniform!�Tt <br /> sand Used Tire Manif California Integrated Waste Management Board <br /> PO Box 1259 Sacramento.CA 95812.1259 <br /> EXAMPLE te <br /> Manifest Number <br /> State of Calllornia+ M ' 1 10 4 2 l I O <br /> CIWMa•847(03K13) INSTRUCTIONS ON BACK <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) �. <br /> ❑ Pick Up � ) �� 1 <br /> O Import from (/"1.Sew vV0 f -r"z <br /> (If outside California State/Country) <br /> ❑ Delivery <br /> CJ Export to <br /> (If outside California State/Country) Hauler's Business Phone <br /> (include area code) <br /> � Hauler Exemption (fir applicable) <br /> ❑ Govemment ❑LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> ❑Agriculture El Common Carrier/ <br /> Z V D - �� Back Haul <br /> Indicate(if applicable)❑ In Transit <br /> Ligense 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,CCA,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 der 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 /> informatio ay result in suspension,revocation,or denial of renewal of the Waste The Hauler Re ' ration pursuant to Public Resources Code section 42960 and may result in civil <br /> penallie p to$25,000 per day,per violation or administrative penalties up to$5,000 per;violatkolper day as described in Public Resources Cooee section 42962. <br /> /,/� -6-2 —102 <br /> fiver's Name(print) river's nature Date <br /> ART II: TO BE COMPLETED BY REPRESENTATIVE O TIRE DEALER OR WASTE TIRE GENERATOR OR ED-USE <br /> FACILITY (please print)-USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. I <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street AddressSame As <br /> 41 0 Address <br /> 0 Change Of Address aider <br /> City State Zip Code <br /> Tire Types and Amounts Intended Use <br /> ❑ Passenger ❑Oversize ❑Retread/Reuse <br /> Tire Program ID Site Suffix <br /> .., ❑ Recycle <br /> eo <br /> LO d Type(check only one) Truck ❑Other <br /> !�Whole Tire Count ❑Welght in Pounds C El Fuel <br /> C <br /> Volume Cubic Yards Weight in Tons C <br /> ❑ ❑ g . ❑Disposal/Landfill <br /> Load Amount O Comment Area <br /> [confidentiality 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 Califomia t at in ation 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 d n tr penalties up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. <br /> epresentative Name(print) Repre ti e' Signature Date 32676 <br /> ■ Toll Free 1-866-89( - ) WWW.CiWMb.Ca.goV/Tires/ <br /> White:CIWMB Copy Pink:Tire DealedGenerator/End-Use Facility Copy Yelbw:Hauler Copy <br />