COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

^''�i 7P'wYr,r•y(,ra� 111'.,{`!„nxl,pnF '.. �n 1”' /^},hi4 41Y','a W h.YtJ� 41!_r FiBI N"S!1r I t 5r "v til- t 1t I. Ir' �'h.• r•, .,15 It 1��O,CS1�[ICl�jwiiv�IN+IO[Jr/� iv� iMY.'�F� ,l.'^'.�.'�1"i",�1( /:�1� 1M1 ��1�� Y,1}L 1• d",'Y f�"'T�T Y`+^� ^V•'Nil'` e�t��UiM'J.RA.i1 3JA.C� ilCA Cdllorrua IMayrMetlWaerotutaoagsmsMBosrtl Unlfol'111 Waste and Used The Manife$t PO BOY1259, SACrarllento,CA 95812.1259 2 3 Manifest Number EjXjAjMjPjLjEj j 1 crW"llD-6:;M'M INSTRUCTIONS ON BACK M 3 - 12 4 7 G 9 Q PART I: TO 8E`COMPLETf?D 13Y TtAE HAUIEtR (please print) []Pick Up ❑import from " ' � s lit outalde CafifornlaBtate/Country) ❑ Delivery ❑Export t0 (if outside Cal ornie 6Sat�7CouMtfy):i Haufer'a 8ualnsae Prions ^ - (Ineluds area code) Hauler Exemption (1f appllC8bl9) 0 fp ❑Government❑LEA Exempt Loaf Dote (MM(DD/YY) Log Number ❑Agriculture I]Common Carrier/ Beck Heul Indicate(It appiicabio)p In Transit License Plate Number State Decal Number ❑Confidentlailty Claim:The Information provided in Part I and Pert it of this form should be considered confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,Should any member of the public request disclosure of this Information,I request that CIWMB correct me at the address and telephone number above. certify that under penalty of perjury undor tho iawe of the State of CalHoinla tnal the informatlon provided above is true and corrobt. In addlbon,I am aware shat falslflt:atiom of this information may raeult in auapemsion,revooaeon,or denial of renewal of the Waste Tire Hauler Registrallon pursuant to Publio Resouroas Code Section 42960 and may result in oivlt penal ie9 up to 625,000 per day,per violation or administrative penallIM up 10 35,000 per violation per day as described In Publio Resources Coda ssulon 42002. L 2 � 1 aljAb�I Driver's Na o(print) Drivor'a 3ionature ate PAAT 11' TO pL COMW6E-'TE60AVP0I`E$I$NMA .01111sW,i1STE TIRE QENI AT A tND-I19E FACILITY (please print)-USE.ACTUAL-LOCATION'WH L�`�' FI �E �IPIt��:� E i�.I�f4ED-UF1 9AiDi9�i3P1+ED�TI°. Business Name Facility's Business Phone (Inofude area code) Number&Street Address ❑ Address Sams As Hauler �.� State ZIp Code E] Change Of AQdraas Tire Types and Amounts �Int�edUse ❑Passenger ❑Oversize euse Tire Program lD l Site$Uffix . ❑Reoyole LoTyplii{theckcnlytonel 4;. ucic ❑other ( mole Tire Count E]Welght in Pounds II Fuel ❑Volume Cubic Yards []weight to Tons 1 ❑ DlsposeVLandfill Load Amount O_ ComrrientArea ❑Confidentiality Claim: The Information provided In Part I and Part II of this form should be considered confidential,proprietary,.andlor trade secret. In accordance with TKIa 14,CCA,Section 17041 et.seq,Should any member of the public request disclosure of this Information, I request that CIWMB conted me at the address and tolephone,number above: I certify that Vow penalty of perjuryunder the laws of the Btete 01 California that the Information ptcywed above Is true .In addli I am aware that felsUkadon of tMs Information may result In civil penalties up to 825,000 per day,per violation or anmtnlatra penalties up to$9,000 on per day as described In Ill Resources Code section 42982. ✓bosh V YSIc; Representative arae FwoselfllwOs Signature Dale �328�76 Tg%II Cres +_aaa_aaa_nann r .annus Murlrnh ^ft M^V11Tlrnei/ r w■ = 1 iiiiiiiii L -d 0666 13rN3SU-1 dH WdEZ :ZT 9002 LO UeC