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.s � d � � :tea - � K •_ <br /> , <br /> 'CA, Uniform Waste and Used Tire M*nlifest CaiifbmiatntegratedWasteManagementf3oara <br /> PO Box 12Wi,Saornm6nto,Ga 95012-1259 ■ <br /> n EXAMPLE 1 2 41 Manifest Number <br /> Stats of Calif { �+ n <br /> eiwr�FB 647(01M) INSTRUCTIONS ON.SACK i ' 'y 5 4.0 4 2 I <br /> Business-Nam <br /> ,1 r <br /> Acidre3EB <br /> City,State, Zip <br /> r Hauler's Business Phone <br /> (include area code) <br /> Hauler Exemption (if applicable) <br /> ❑ Government ❑LEA Exempt <br /> p <br /> Load Date (MM/DD/YY} Log RN..er Agricultureµ-- ❑.Common Carrierl <br /> Back Hau( <br /> � indicateusable}❑'In Transit <br /> if a <br /> _Licen_s_e_Plate Number State Decal Number_ { pp <br /> ❑Confidentlality Claim:The information provided in Part I and Part fl of this form should be considered confidential,proprietary,and/or trade se$ret. In <br /> accordance Wlth Title 14,CCR,Section 17041 et.seq,Should any member of the public request disclosure of this information, I request that CIWL48 contact <br /> me at the address and telephone number above. <br /> f oerttty that under penalty of perjury under the laws of the State of California that the Information provided above is true and correct. In addittbn,1 am aware that falSKication-of this <br /> information may result in suspension,eevoeadon,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resoure"Code section 429,60 antl may result in civil <br /> II up to 525,000 per day,perviolattlon or administratLye penalties up10$5,000 pervrol don per day as dcfscribad In Public Raeourees Code section 42962. - <br /> c, i .1e <br /> Driver's Ntime(Print) <br /> D�v'rr nature <br /> Date <br /> '[,7 <br /> 3u iness Name, Facility's Business Phone (include area code) <br /> L ___ i i t i 1 t i i i i i I i. I I t <br /> Number&Street Address <br /> _ ❑Address same As Hauler <br /> t �1 , j {, , C.R ? ❑Ghan a Of Address <br /> L. �� i i i 1 i—1�J—�.J �.....,1_.._.J I 1' 1 '�l�d 9 <br /> Cts State Zip Code <br /> r Tire Types and Amounts Intended Use <br /> 1 f <br /> ❑Passsn ger <br /> ❑ Oversize ❑ Retread/Reuse <br /> Tire Program–WI Site Suffix ,m ❑ Recycle <br /> ,E E <br /> I : e, ❑Truck ❑Other <br /> LII ';u"'DispU n fill <br /> Comment Area ❑ <br /> ❑Confidentiality Claim: The information provided in Part i and Part li of this form should be considered confidential,proprietary,and/or trade secret. <br /> In accordance with Title 14,CCR,Section 17041 imseq,should any member of the public request disclosure of this information,i request that C1Wla <br /> contact me at the address and telephone number above. <br /> I certihj that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,f am aware that falsification-of this <br /> information may result in civil penaltles up to$25,000 per day,per violation or administrative penalties up`to 55,000 per violation per dayas desCnbad in Public Resources Code <br /> section 42962. <br /> r <br /> Representative Name(print) Represeritative's Signature Date 32878 <br /> so•d 6I:9T soot IT tnr <br />