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�cOl ;+l` ,yfy:j(":yrr .`f?tCk��yL,!{7tLvn�r'. � t'y+W t w171 th.;" -M( '�i l Gellfomia Integrated Waste Management scald ■ _°° CA Uniform Waste and Used The Manifest PO Bmf 1259, Sacramanto,CA 9912.1259 " EXAMPLE 1 2 3 M. 9 - 1247688 '' (AManifest Number ciwitilli aioi INSTRUCTIONS ON SACK M a - 1 2 4 7 6 8 8 PAIN I: Ta DU tla� ❑ Pick Up M Import from (if outside California Statei(Country) ❑Delivery ❑Export to (If outside CaUfottrlle latelDa(untry)I Hau9uPhone (include � ' _ 4"t 1 -1 ncfude"Area a coos) Hauler Exemption (it applicable) 1 I l !� I ! j��j ❑Government ❑LEA Exemot Load Date(mmIDD/YY) Log Number �Agriculture ❑Common Carrlerl Q f J� / _ NICK Haul rl 44 o44 o, q i .j 7 Indicate(i(opplicebte):3 In Trantsit License Plate Number S4ete Decal Number ❑Confidentiality Claim:The Information provided In Part I and Part 11 of this form should be considered conficomle,proprietary,and/or trade secret. In accordance with The 14,CCR,Section 17041 el.eeq,should any member of the public request disclosure of this information,I request that CIWMB contact me at the address and telephone numberabove. f certify that under penalty of perjury unde'the IQYA of the SI9te of Calllornla that the Inlonnalion provided above Is true and correct. In addlP.or,+am aware!761 feiaifitation o!lti s Irformailor may result In suspension revocation,or denim of renewal of the Wass Tire lrau!er AGglatrerion pursuant to Public Resources Code section 42980and may result in civil penalties up to$25 o0o as,day,per violation or administrative penalttee up to$5.000 per violation per day as deaoribed in Public Resources Code aeriion 42892. -Driver's Na a rine) ; �D� $ i nature ,, ,. D„ e (P PAitIT#: Td sE ESvMIQ1'Etb Hi�'RBPIiV' t 191811y tNREEW�►EAtt :if >i10:11SS FACILITY(please print)-USE ACTUAL 11�.00APQN I%,' $04 PicKSb-,UO-DR DROPPED•OFF• Business Name Facility's Suslness Phone (Include area code) Number&Street Address r� h � r-y � � ❑Addrese Sema AS Hauler T' ��t v� �, �e��Pl�( /✓� ❑ CnangaofAddress City 9 mate ' Zip Code Tire Types and Amounts Intended Use ` ❑Passenger ❑Oversize read/Reuse Tire Prog m 1 Slte S r Q Reoyole Load Type(phsok•only-P,! j A ruclt ❑ Other �fl is Tire Count waiept in F�ouaas. I Fuel ❑ Volume Cubo Yerds ❑Weight In Tone � ❑ DispoaaULandfNl i Load Amount Comment Area ❑Confidentiality Claim: The Information provided In Pan I and Part II of this form should be considered confidential,proprietary,and/or tratdo secret. In accordance with Tfue 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this Information. I request that CIWMB Contact me at the address and telephone numbs,above. I eartoy that under panalty d poduy u roar the Iowa of the state of CalAomla that the information provided stove Is true and correct.In addition,I em aware that falsikat on of[hie lnlorrnatlo�may rasolt In civil penalties up to$25,000 per day,per violation or administrative penalties up to$6,000 per vioiadrin er day as deacribed In Puello Resources Code section 4202. Representative N me(print) Re entaeWVw-rIwmh.ca.aov/T1rea/ gnaturo Date, 32876 fl• TmIl Fran i-ARR_AQR-nRnn ,+ r M ■tt 9 -d OCCE 13CN3Sd-1 dH WJ22 :21 9002 LO UeC