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<br /> ■ CA Uniform Waste and Used Tire Manifest Capp Box t�flt�nte�,t►CA msi2,2g
<br /> Manifest Number
<br /> EXAMRLE 123 . ._ .
<br /> 111141"aCow«.111 ``AA +
<br /> cftrra�eae,lt�sm), INSTRUCTIONS ON BACK........,.:..., _..... ......... „.... ..... .. . ,... :. Itli..6.�:.! .2 4 .7.. 6 9...3.
<br /> I PART 1: T®` C IIPtwETEO. Y T�9l;y WR�lpl�RBl
<br /> . i❑ Plill lip
<br /> ❑Import irorn i
<br /> i (If outside C411t6nni8 ta1al.57Ur11,V) �� Vb 0-k-,x
<br /> 10Delivery �. Zl
<br /> ❑ Export to Neuter's 8uainea9 Phone
<br /> (if outside California Stete/Coufltry)i ( _
<br /> i (include area code) l �O (� Oq Ct
<br /> Hauler Exemption apocatol
<br /> Load DHte (IV1fwl7DlYY) 11 Log Number ` 7 D L3 Government❑LEA Exempt
<br /> Agriculture ❑Common Carrier/
<br /> Beck Haul
<br /> 0., lJ �D Indicate(If applicable)Lj In Transit
<br /> License Plate Number state Decal tuber
<br /> ❑Confldenttelity Claim: The Information provided In Pert I and Part II of tflls form should be cons Ida red confidential,proprietary,and/cr trade secret. In
<br /> accordaue with Title 14,CCR,Section 17041 et.seq,should any member of the public requeel disclosure of this Information,I request that CIWMB contact
<br /> me at the address and telephone number above.
<br /> I certify that under penalty of perlury under the laws of the State of Cditrnla that the Information provided agave is true and r o c In on, m ewers that laiatlkatlen of mit
<br /> Information may result in suspension,revocation.or denial of renewal of rho Waste Tire Ha R ur a Code a ctIM 42080 and may Neufl;n civil
<br /> pa�alti6t up In SMC40 per day,per vlolatlon or administrative penallles it)-.o 95,00()per vlo per wribal bill mea Cc t:eerton 42989
<br /> L>� ��' t, ZZ&OInv
<br /> Driver's Name(print) Driver' I r ate
<br /> Rlkt9fi I ; 'I.4�E L'OMPI. rEd51r1 ( tri :-.� ... '�i�1!114 'SWp-t�$L°
<br /> 10
<br /> FACILITY(please print) USE ACTUALC T'll: tl WMiILR9 THS AFIE PDAOPPI:410l
<br /> Business Name Fat:iHy'a ualnet a Phone(Include area codej
<br /> l (0 1p Q'c_Il5
<br /> Number&Stref ddreas
<br /> t _„ ❑Address Bante As Hauler'
<br /> �- ` 3 o Charge Of Addreee
<br /> City S Zip� Code ,
<br /> Tire Types and Amounts Intended Use
<br /> f 0 I ❑ C3 Passenger ❑Oversize Retread/Rsuss
<br /> Tire Program ID sit e991
<br /> Low Typft;'(cheok drily one rruck Other Fuel
<br /> Q'%hola.Tlre. Count WetgKs In PoundB' � L]
<br /> Volume CUM Yards O Vyel0drf-Tape ,
<br /> ❑Docaslrtandflll
<br /> Load Amount Comment Area
<br /> /5- 1
<br /> ❑Contldentiellty Claim: The Informatlon provided In Part I and Pan II of this form mould be conslaerecl conirdenlial,proprietary,and/or trade secret.
<br /> In acco dance with Title 14, CCR,Section 17041 et.eeq,should any member of the public request disclosure of this information,1 request that CIWMB
<br /> contact me at the address and telephone number above.
<br /> i certify that under penalty Of perjury under fits laws ofthe State of C6llfornia that the inrormetion provided above is true and cot n addition,I am aware that ialaticatlan of Ih s
<br /> information may result in emi penanles up to$25.000 per day,per violation or aeminletraave penalties up to$5,poo per r day as detoribed In Public Resourpait Code
<br /> section 42se2.
<br /> ✓Josh �1�5�coc`, 'Zi - /
<br /> Representative erne(print) entat a Signature Date 928713
<br /> ti Tnll Cron i_QRR_Q�G_ARIf4A / trims/{t/ ,ritarw►h wn ntna►/Tlrnn/ po seen seem esss�
<br /> G -d OEEE 13CN3Sd_1 JH WdS2t21 9002 LO ueC
<br />
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