Laserfiche WebLink
Ca!VQrrIa Integrated Waste Managament Opera <br /> CA Uniform Waste and Used Tire Manifest PO Bom 1239, eacni CA 95012-126a <br /> [-EjX-jAjMjPjLjE1 111213 Manifest Number <br /> am Of C*m*"" <br /> INSTRUCTIONS ON BACK M 5 12 4 7 6 9 2 <br /> ;0:tftk U <br /> C)IM00,11 Iftli <br /> cW24 S— <br /> Delivery <br /> [I Export to i Hatlers Busirabs Phone <br /> (11 oulaide,0 con") i (Include area code) <br /> q q <br /> C L4 Hauler Exemption (if applicable) <br /> 0 Government C] LEA Exempt <br /> Load Date (mviEm/yy) Log Number 0 Agriculture [3 Corilmon Carter/ <br /> Back Haul <br /> lndlc*te(if applicable)[I In Tranait <br /> License Plate Number 6 State Decal Number <br /> ElConfildentlailty Claim:The trif6rri provided In Part I aro Part it of the form should be Con eld6red conl dertial,proprietary,ardor trace secrai.in <br /> accordance with Title 14,CCA,Section 17041 at.seq,should any member of the pubille request disclosure of this information,11 request that CIWMB Comsat <br /> me at the address siric telephone number above. <br /> I cortity mat under penalty of perjury under the Iowa at Ina State of Calilorrila that the Information provided ahoQ tru d carre d1i I am aware that fetislflculior Q1:his <br /> 11 <br /> Information may riii In suspension revoci or denial of renewal of the Waste 71 LFf&fAnt P bila R u Code sei 42eeO and may roautt in civil <br /> )0, <br /> perishes 61p to s2ii per day,per vdoiatlnn or admiriAtrative penalties up to$s o00 a .,I pe y a Ir Fi e soi,r as Code"olon 42911 <br /> i4�w P— <br /> Driver's Name tiorint) Driv a D <br /> PART A, TO BE COMM ITO AV '111111 WASTE TIRIE AWN01.W- 400,�69 9114,0,09E <br /> IL ff, Y(pidprin <br /> a" t, -.USE ACTUAL:LOCAL ION-WH & <br /> TTIMS ARE016KED-UP OR DA00 `9 0115- <br /> �2 41 - 41 ID <br /> ' ve Business PhOnG(include area code) <br /> Business Name Fs6 kin <br /> Number Stread Addrem <br /> Address Same As Hat,ler <br /> Charge Of Addreso <br /> City State J�c <br /> Tire Types and Amounts Intended Use <br /> Passenger [3 oversize �etreed/Aetse <br /> 4"" C) <br /> T(rie'Progirarrit(b site suffix <br /> --------- Ll Recycle <br /> A&0 Type.(imetwortiv other Fuel <br /> E!rwhole Ins Collilm walght In ftuirldbi <br /> Volume Cubic Yards Welght InIONS C DISP06aVLandiiii <br /> I Land Amount Comment Area <br /> []Confidentiality Claim: The Information provided In Part I and Part 11 of this form should 13e considered confidential,proprietary,and/or trade secret. <br /> In accordance with Title 14,Cl Section 17041 et.seq,should any member of the public request disciosurs of this information,I Squeal that CIWMB <br /> contact me at the address and telephone number above. <br /> I carlify!h&t under Penalty of perjury under the laws of the Stale of California ftt the Information provided above I I 4aWed In addition I am aware that falaitowlen of thla <br /> Information may ra"it In civil persit"up to$25,000 per day,per violallor cr admin] trati poi Lip to$6on per day as described In Public Resources Code <br /> se&Dn 42962 <br /> Representative Name(print) Rewents"As signature Date 32e76 <br /> Toll Free 1-966-896-0600 / www.clwmb.ca.aov/Tiroe/ FMS <br /> 0T 'd OCCE I3C213SIJI dH Wc!92 :21 9002 LO UeC <br />