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acu 'w , <br /> A- 'if'i#orm Wase. and Used Tire`Man�fes CalifomiaIntegrated Waste Management Board <br /> ■ PO Box 1259, Sacramento,CA,95812=125 �, <br /> ligili.. . E XUN <br /> 'A IVL P' 'L 1'.2 3 Manifest Number <br /> Staeeutcahfnrnia 6A <br /> H, ,•, - .:. :...' .:. fl-• ,:$-•"O': � <br /> ctwbe-647(0103) <br /> Hauler <br /> (optrof i Address Labe!) <br /> Business Name _� <br /> Address . <br /> City. State, Zip - T�v 1 _�f u j <br /> F(auler's Business Phone <br /> (include area code] <br /> .. <br /> � Hauler Exemption (if"applicable) <br /> S. ❑ Cavbmment L EA"�zerppt <br /> j'.Load ate (MM/DD/YY); : ,LOg Number <br /> J. 2 :� <br /> -Aghculture',- Common Carrier/' <br /> `Back Haul,. : <br /> : J Indicate(if applicable}[] In.Transit'. <br /> License Plate Number,' ."... " :.:State:': Decal Nurmber. : 'w <br /> E]Confidentiality Claim.:Tho informatiomprovidedin Part.]and:Part Il of,this form should beconsidered confidential,"p-roprietary:.and/or trade secret. In <br /> Y x accordance'with Title_t 4,CCR Section 17D41 et seq should any member of#lie public;reques#disclosure of thisrtnformation bequest that CIWMB contact <br /> me at the atldress and telephone number akiove k" s= rf ; <br /> I certify that under penally of perjury'under the'Ga ;.: t the State of California'that the information provided above is,true'and'oorreci. In'addit'ion I am aware thaEfalsrfioatson of this i` _ - <br /> information may result in suspension;revocation,or denial'of renewal of.the,Waste Tire Hauler Registration pursuant'.to Public'Resources Code sectiorY 42960 and may result in civil r <br /> ".penalties up to$?5 00 per day,per ftlation'or administrative-penalties up to$5,000 per violat(on,perday as,de scribed'in Public Resources Code section_42962~ <br /> Driver's Name rinf river's Signature Date <br /> (optional Address Labe!) k <br /> Business Name Facility's Bus'IheSs,"Phand'(inclu"de arealo j <br /> 'Number,&Street Add_ ress <br /> ❑'Ad_dress Same As Hauler f <br /> / _ Yx <br /> �' ❑Change Of Address <br /> . <br /> City Y State Zip Code <br /> Ttre:Types and Amounts Intended Use . <br /> [] Passenger ❑ Oversize." RetreadlReuse ' <br /> Q . S ❑: <br /> re Program ID Site suffix <br /> CIO <br /> .. ck [] Other :.❑ Fuer - <br /> d. ❑ DisposallLandfil4 <br /> Comment Area s a E r r x <br /> ❑Confidentiality.Claim."The information provided in"Part l and Part Il 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 reques!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,1 am'aLware that fals`iiication of this <br /> information may result in civil penalties up to$25;000 per day,per violation or administrative penalties up to$5;000 per Jioiation per.day as described in.Public Resources Code <br /> section'42962 :'•� >. <br /> Representative Name(print) ' .. Representative`s Signature Date s2e�s rJ <br /> Tvl!~Free'i=866=896-06001 *ww.clwmb ca. ov/Tliresl <br /> ' g � - <br />