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FROM :CALA(IERAS GARAGE FA;' t10. :209-464-5126 Dec. 23 2004 10:49AM P4
<br /> r
<br /> State of California California Integrated Waste Management Board
<br /> CIWMB-62 (5/2001) 1001 "1" Street, P.O. Box 4025 • Sacramento, CA 95812
<br /> WASTE TIRE HAULER MANIFEST 1191255
<br /> INSTRUCTIONS ARE ON REVERSE 81DE OF FORM
<br /> PART 1. TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WAS--
<br /> Tire Dealer/Generator (include Board of Equalization "Tire Recycling Fee Acco CALAVERAS GARAGE 13D/CA
<br /> Name &Address 40 SOUTH UNION ST.
<br /> STOCKTON 95205
<br /> County (Area Code) Telephone Number
<br /> (209)-464-4384
<br /> I Date of icku (Month/Day)year) _
<br /> Whol s in this Shipment OR— Volume of Tires in this Shipment Weight of Tires in This Shipment
<br /> Sires (cubic yards) OR— (Circle One) pounds tons
<br /> 1 1 certify t n provided above is true and correct. i certify that Part 2(a) and Part 3(a) were completed at the time of this certification. I
<br /> am aware that falsification of this manifest may result in civil penalties or administrative civil penalties as described in Public Resources Code Section
<br /> 42962(a) and(b). (See reverse side of this form)
<br /> Waste Tire Deal er/Genaratt�or Representative Signature
<br /> � 2-Date Lr 0l Printed Name
<br /> PART 2. TO BE COMPLETED BY REPRESENTATIVE OF WASTE TIRE HAULER
<br /> (a) t
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<br /> PART 3. TO BE COMPLETED BY REPRESENTATIVES OF WASTE TIRE HAULER AND DESTINATION SITE
<br /> (a) TO BE COMPLETED BY WASTE TIRE HAULER, TO BE CORRECTED BY DESTINATION SITE IF DIFFERENT.
<br /> Destination Site (include CIWMB Site Number if known) -0656
<br /> Golden By-Products, ]no, P.O. Box 1
<br /> Name&Address 13000 Newport Rd SaIlleo, CA 95303
<br /> County Merced (Area Codo) Telephone Number 209-666-4665
<br /> (b) TO BE COMPLETED BY DESTINATION SITE
<br /> Date Tires Received (Month/Day/Year)
<br /> Are the number of tires received the same as the number of tires shipped in Part I? El Yes L No If NO, please
<br /> complete the box(es) below:
<br /> Whole Tires in this Shipment OR— Volume of tires in this Shipment Weight of tires in this Shipment
<br /> (cubic yds ) OR— (Circle one) pounds tons
<br /> I certify that the information provided above is true and correct and that I have been authorized by the State of California or a local agency permit to
<br /> accept waste tires for reuse or disposal. I am aware that falsification of this manifest may result in civil penalties or administrative civil penalties as
<br /> described in Public Resources Code Section 42962 (a) and W. (See reverse side of this form)
<br /> Waste Tire Destinatlon Representative Signature
<br />
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