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California Integrated Waste Management Board <br /> CA Uniform Aaste and Used Tire Ma nll PO Box 1259, Sacramento,CA 95812-1259 <br /> •i's" E I X I A I M I P I L 112731 Manifest Number(� <br /> stata0lcallfomle INSTRUCTIONS ON BACK - 1.1 5 - 12 10 0 6 <br /> CIWMB-647(03!03) �A <br /> I A : TO BE COMPLETED BY TIRE HAULER (please print) <br /> ck Up A <br /> 11p <br /> Import from �/ �4e <br /> (It outside California State/Country) <br /> slivery 7�jU. C .NQS <br /> ❑ Export to <br /> (it outside Califomia State/Country) Hauler's Business Phone ` <br /> (include area code) <br /> — Hauler Exemption (if applicable) <br /> c) L � loo 733 <br /> ❑Government El LEA Exempt <br /> Load Date (MWDD/YY) Log Number <br /> ❑Agriculture El Common Carrier/ <br /> 7 7 Back Haul <br /> [ rf V 3 0 S / Indicate(if applicable)❑In Transit <br /> 7on <br /> se Plate Number State Decal Number <br /> fidentiality 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 provided above Is true and correct. In addition,I am aware that falsification of this <br /> information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Rlstrfltlon pursuant to Public Resources Cade section 42960 and may result in civil <br /> pem Iti up to$25,000 per day,per violation or administrative penalties up to$5,000 per viol n per day as de ibad In Public Resources Code section 42962. <br /> Driver's Nam (print) river Ignature 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 /> U-) ay `�c ( C�, 4 ii� ) �/ r S - 3 .2, 6 ':;? - <br /> Business Nacre Facility's Business Phone (include area code) <br /> I S37 r MA -- <br /> Number&Street Address <br /> / S1l (� ❑Address Same As Hauler <br /> \ 0 ` k •�. �j C A C S C) ❑Change Of Address <br /> City tate Zlp Code <br /> h 1 Tire Types and Amounts Intended Use <br /> ❑Passenger ❑Oversize []Retread/Reuse <br /> Tire Program ID �I 1 \ Site Suffix <br /> ❑Recycle <br /> LO_0 Type(check only one) ruck ❑Other <br /> Vhole Tire Count ❑Weight In Pounds y Fuel <br /> Volume Cubic Yards ❑Weight in ToneD ❑Disposal/Landfill <br /> Load Amount G Comment Area <br /> R.'ro'nfidentiallty 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 /> in on ma uri In civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described In Public Resources Code <br /> sect' 2962 <br /> Q 7 /6 �3 <br /> epresentative Name(print) Representative'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 />