Laserfiche WebLink
California Management-1259 <br /> Uniform Waste and Used Tire Manifest Pb GoA 1269,aloo Waste ManageSavwnei CA 09212-1349 <br /> LE I�Am LP E I L=F T,T2 31 Manifest Number <br /> state up cajo�ln <br /> C(*M&447fG3M) INSTRUCTIONS ON BACK M4 - 1276575 11 <br /> flouterlow <br /> opt,rj;i2! <br /> 8usinp_%ii <br /> A,,-0 JON"PADILLA TIRE DISMAL <br /> PadiRs's Tire Disposal <br /> City P.O. Box 1035 <br /> LkWiea,CA 95236 <br /> 09 , 10 <br /> Hilluter'S Business Phone <br /> (Include arm code) 04 <br /> Mauler Exemption (it appiicabjej <br /> Govarnmeril 0 LEA Exempt <br /> Load Date(Muloo/yy) Log Number 0 Agdcuhure 0❑Common Carrier' <br /> • <br /> Back Flaul <br /> k"" Indicate(ii applicable)E]in Transit Q- <br /> J <br /> License Plate Number State Decal Number <br /> OConfidentiality Claim:The information provided in Pan I and Part 11 of this form should be considered confidential,proprietary,and/or trade secretin <br /> accordance with Title 14.OCR Section 17041 et.seq,should,any member of the public request disclosure of this information.I request that CIWM8 contact <br /> me at the address and telephone number above. u I )I <br /> I cenity that under penalty,of pietiwy under tris laws of the State of California mat me mocmaiton provided above is true&no correct. in addition,i am avvore mat falsification 44 INS 0 <br /> information rn@y result in suspension,revocation,or denial of renewal or me Wasle Tire Hauler Registration pursuant to Public Resources Code section 42980 and may reftit in civil <br /> p"ies up 10$25,000 w 4111y,per vioks6or,or administrative penalties up to$5,000 per 0.91411 per day as de"bed in Publi�Resources Code section 42962. <br /> --I Driver's Name pint shiver's nature Date <br /> C 1111 0111 <br /> Business 1,16-me Facility's Business Phone(include area code) <br /> jJ <br /> Street Address <br /> 0 Address Same As Hauler <br /> 0 ce)angel 01 Addtiiiar, <br /> • State <br /> _. Code <br /> Tire Types and Amounts Intended Use <br /> assenger 0 Oversize <br /> 0 Retread/Fteuse <br /> I_ <br /> Tire"ram 10 Site Suffix <br /> L _ ❑Recycle <br /> i I <br /> C3 Truck 0 Other <br /> 0 Fuel <br /> 0 Di3pos&VLancifill <br /> Comment Area <br /> )CConfidentiality Claim.The information provided in Part I and Pad If of this form should be Considered confidential,proprietary,and/or trade secret. <br /> Aaccordance with Title 14,CCR.Section 17041et.9eq,should any member of the public request disclosure of this inicirn126041,I MQU"I that CIWMI3 <br /> contact me at the address and telephone number above. <br /> I oartity inav Lwicter penalty of perjury vnftf the Ws of the State of Calitomia tnat the information provided above is 1"and correct In addition,I am award that pals ricafi9n or MS <br /> information m"result in civil penalties up to 525,000 per day,per violation of administrative pen&IIJOS up to$5.000 per vioiation per day as described in Public Resources Code <br /> section 429824 <br /> Representative Name(punt)`,' Representative's Signature Date :32876 <br /> Toll Free 1-866-896-1 l0600 / www.ciwmb.ca.gov/Tires/ <br /> M Wnite:CiwmB Copy :Pink;Tire DeateriGenanitioriEN-1,160 Facility Copy Yellow:Hauler Copy <br /> -A. <br /> 10 39Vd 1VHASStJ17bl 0ZGEV66 8Z:9T V00Z/t71_/90 <br />