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's •CA Uniform Waste and Used 'Tire Manifest . ca"O"ialntegraI"dwaste ManagementBoard <br /> PO Box 12W..Sacramento,CA 95812.1259 <br /> _:--: EXAM,P L E 1 2 3 Manifest Number <br /> Stile of 4'etlfdrnle <br /> INSTRUCTIONS ON BACK 9 - 12 4 7 8 8 6 <br /> ciwatt�a�osost <br /> ry M,C if?�ftf3t �0��toralct�rp,SS � boff <br /> .sI ss Narn£t y <br /> Addlres5 <br /> x � c Citi, Stat%, Zip <br /> �b;A�� ✓ t , a Hauler's Business Phone <br /> ��.', u", (;ncludi�area coat:)��� <br /> 1(��a I ✓ I d L — ' Hauler Exemption (ir applicable) <br /> I - JIT- C [ l <br /> ❑Government LEA Exem <br /> �1_.� o pt <br /> Load Date (Mm1[)[)Yv) Log Number <br /> L <br /> -• [IAgriculture. Q Common Carrier/ <br /> .. Back Haul'. <br /> 7 �rl 119 <br /> _0j F <br /> Indicate(if applicable) �ransif <br /> Licens_g^ Ill ate Number State. Decal_Num_ber . <br /> ❑Confidentiality Claim: The Information provided in Part i and Part if of this form should be considered confidential,.proprietary,and/or trade Secret.Ir <br /> accordance with Title 14,CCR,Section 17041;et.seq,shoyId anymember of the puklrc request disclosure of this information,I request that or trade <br /> .g contact <br /> me at tfle address and telephone number abdVe <br /> . . <br /> I certify that untler penalty of perjury untlst the laws or the Stare of Cafirornia that the Inforrnation rovrdStf above is true ani OOrratt. in addition,i am aware that fa{3iticatian of this' <br /> Information may resull in sus ension,(evocation,or denial of renewal of the Waste The Hauler Registration pursuanno Public ReWurcsa Code sectwnA"eo and may result In civil,. <br /> penalties up to 325,000 per day,per violation or administrative penalties up to$5,000,per vidlalion per tlay as described In Puolld Resource^,Code Section 42962. <br /> Driver's Name( rant _ Driver's Signature Date <br /> C• iti%til ��l/ G/�fr� _ <br /> BUM (--SS Name �— Facility's Business Phone (include area code) <br /> Number&Street Address <br /> t/V []Addres i.Same As Hauler <br /> LEL <br /> ` {`f_iL�_L .J.'�L--1 1 t I l.�L J 1 I I l_._ �_J I Tt I Ll Change bf Address <br /> City_ State Zip Code <br /> Tire.Types and Amounts <br /> Int sn d Use <br /> J ❑PassengerEli] <br /> ❑Oversize <br /> Reuse <br /> Tire ID Site Suffix r <br /> L Lecycle <br /> zir ❑Truck ❑Other p Fuel <br /> e ������ ❑ DisposalfLandfiA <br /> l <br /> Con!rtlentArea _ <br /> pCOnfidenti8tity Cieim: The information provided in Part I and Part if of this form should be considered confldentiai,proprietary,and/or trade secret. <br /> in accordance with Title 14, CCA,Section 17041 et.seq,should any member of the public request disclosure of this information,I request that CIWM8 <br /> contact me at the address and telephone number above: <br /> I Cenify that under panafty a petrjury under 1110 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 10$25,000 per day,per violation or administrative penalties up to$5,000 per violation per tlay as described In Public Resources Code <br /> section 42962. �, . <br /> Representative Name(print) Representative's`Signature Date zPa7A <br /> 20'd T T:91 SOOZ TT T nr <br />