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..:....,.,,.. �....p1.y - r .�.._..... •y,•w^...., �'i�d;:r, }� •��r,�." ��x s'+ .'C7h' � �& -s: IIT �d �` p"C,. k �" fa h`.'''•; I G 3 7 r J.r, f ''r.q .'f` r� � !.I .'tlk, 1't' CA Uniform Waste and Used Tire Manifest California, 1 ,19, d WpateMana 95812 Board ■ '__� PO Sox 12,19, Secramanlo,Ca 9tie12-t269 • ' EXAMPLEj 1112T[3 Manifest Number Cha ei soaps) INSTRUCTIONS ON BACK M4 - 1247691 PST i _TO @B'Cfi�1NI�RLE1°E�9 TI1if-HAWk�Arl pfint) i E Plak up ❑Impvrt:lrortt W.•ro►�� w�� (ff.outa'de Cethfor ls, txts(Countpy) ! 7i- ON ❑ Delivery Q z � ❑Export to t Haulere auslness Phone (n outside all ornla te'Qaitri(ry),I (ineJuds area code) zQ ; /� 2_ /�,{ _ �1 l '� Hauler Exemption (n appilcable) 1 / / f �.J tG�—' ❑Gove nment❑LEA Exempt Load Date (MWDD/YY) Log Number ❑Agriculture C3 Common Carrier/ Back Haul 11�► Q (� `� (� `7 Indicate(if appaceble)E: In Trari3f License Plate Number State Decal umber :]Confidentiality Claim: The information provided In Part I and Part 11 of this form should be oonsidared confidential, proprietary.andfor trade secret in accordance with Title 14,CCR,Section 17041 et.aeq, should any member of the public request disclosure of this nformstion.I request that CIWMB contact me at the address and telephone number above. I can fy that under"ralry of parjury under the laws 61 1"State of Callfornia that the information provided above Ie true and correel In addition,I am aware that falslfeat'on 01 th4 Informwian may result lin suspension,revocation,or derlal of renewal of the Waste Tire Hauler Registration pursuant 10 Public Reequ ce9 Code aMlor 42960 and may result in ch it pena'ties up to$25 CCA per day,per v olatwn or administrative penalties up to$5,000 per viola�tiotn per day as described 11 PublIC Resourzes Code sei;Wn 420,6,2. Driver's N me - t 4J Lel�� (print) Drivers Signature Mite I PART Il TO 8H -0UPLti TkDr 1Y i4#1tIlii 1 1 tBlt: lk 4 i�fi$MO�USIF FACILITY please print� L1SE;111C=kAlf'tc'3Ck ' Ibi ? 'IE Ali£F.ICKED•tiP ly Business Name Foollity's Business Phone(include area code) Number&Street Address ❑Address Game tie Hauler ❑ han Cge 0fAddre6a City State Zip Code The Types and Amounts Intend d Use 461 ' o ❑Passenger ❑Overelze sitreed,rReuse G y, Tire Prog am I 81te Sulx ❑ Reayole LOO T pts(ofiertK,cniy prl� .. , rush ❑Other ❑ Fuel Whol i[ e Tiro,6ount [�Weight rn:06.0AOs.: Q Volume CtibleYards wools f.inTiang•: ❑OlsposaVLandfill I`Load Amount Comment Area .......... J I �.*• ❑Con11dentisilty Cialm:The Informatlon provided In Pert I and Part II of this form should be considered confidential,proprietary,and/or trade secret. In accordance with Tide 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information, I requssl that CIWMB contact me at the address and telephone number above. I certify that under penalty of per;ury under the laws of the State or California that the Information provided above is true aro correct.In additon,I ern ewaro that faliftation of Inle Information may resuit In elvli peva liss up to$25,000 per day per violation or administrative penalties up w 15,000 per vlolaVon per day as descried In Pubtic Resouroaa Coce section 42902. l RepresentatIv Name (print) R"SentatiiM Signature Date 32876 Itttta Tnll Crean !_ARR_AGA_nann i �turuaai r+iaiurrs{� esnr<ifTlreQ/ �� g -c! OEEE 13C213Sd-1 dH Wd T Z s Z T 9002 LO UeC