|
11/30/2005 14:221 FAX 2099573972 FedExKinko's R002/005
<br /> r Mat ftitra
<br /> fiA Uniform Waste and Used Tire Manifest
<br /> 6ox 1'7rz). :;:ii,mil"Allu.(,',I 'tj
<br /> •
<br /> ' 1 3 Manifest X;A M;P L F
<br /> Number
<br /> ,tit.of callf.'rig,
<br /> INSTRUCTIONS ON BACK DO NOT TAPE STAPLE 01; DUPLICATE
<br /> :W;t.Vw�iyperul)
<br /> Dy r-ijpjij-t,l if
<br /> •popwit;itywidjor a tram?
<br /> iirld N`4i'.p1w,io.wir,f,cr rl"'�"`:'�L! Y rrlj�;Infurinz,
<br /> Ilion.ttu& wplk Vtli coritact 11""?61111,*.rfsj It!INS femm of wo Lvja,,,u.:�
<br /> Cn
<br /> PART 1: TO BE COMPLETED BY TIRE HAULER .. ....
<br /> P1-'EASE:PRINT-.A'AwV_--`-
<br /> Hauler
<br /> 7
<br /> Ack U F r
<br /> Delivery
<br /> f3uslness
<br /> P10j,s0':'CbrrlpI0t0 if out"jide, C�jjifoj-nij Addross N
<br /> City. statc, zip
<br /> 1171T)ort/Exporf
<br /> Haulef's
<br /> /Country
<br /> .:7"
<br /> Load Date (MM,-nD/YY) Log Number Hauler Exemption to"Ipplicable)
<br /> LJ Goveinoic,rit LJ U-_A Fxempt
<br /> L
<br /> License Plate Number State Decal Number U Rack 11:1111
<br /> Indicate (i(applicabia)
<br /> nadir j
<br /> inforfic,tiot,inay it.*ka,in r�jjr, and rorrmf. lt, f
<br /> III 11w 1jV;1-lo
<br /> PaIliC
<br /> y.por violawin tit .,p 10rd:r -K:V*tM V960 ciria 111-11V 105A III NV?1
<br /> Pt up to S2!;,0(.* in pl4q,t;
<br /> ?
<br /> Driver's Name�,)Pjjq,
<br /> Driver's Sign-iltu-i-c "
<br /> Date
<br /> PART IL TO BE-COMPLETED SY:REPRESENTATIVE OF TIRE DEALER OR WASTES.TINFOENEAAT
<br /> .U.SE ACTUAL.LOCATION WHERE THE OR,.OR.END U
<br /> TIRES ARE PICKED-UP OR DROPPED OFF SE FACILITY-
<br /> iness, Name
<br /> PRINT FIRMLY
<br /> Facility's Business Phone (mirlude arra,rode)
<br /> Number & Street Address
<br /> City
<br /> State zip Code
<br /> "11MO X'.tlawor
<br /> (11-190 Of A(ldirtiss
<br /> Tire Program ID Site Suffix L90d Type
<br /> lc h a C. on-*. Load AMOU
<br /> nt
<br /> 'k
<br /> vVeNight ill Pow Ids
<br /> D Whole Tire Coup •:.
<br /> ...............
<br /> V041 t j *,,:
<br /> ne cubi*,6:*Y,��'64 Wok lit In Tons' --Wh61t-'N'i-rr�h0A;6l
<br /> n jfr�,,
<br /> Tirr
<br /> Awntinr
<br /> CU im Amount filli;*1ded thp
<br /> D
<br /> rZ Rmeyckt Fuel
<br /> Tl-ur-k Amour I
<br /> 0 Olhor Arnowill G(,wiy)nin1 Art3a
<br /> CL
<br /> 0 •
<br /> pa0.-.11jy L"'t ln,kir;r life brw,,o!01.:
<br /> in,jjjjj,j;rn.
<br /> mfnrrfs'jtir�rj ol;jy fir�!Ivij�Kinaftw�� [)L-V Jay.lr.�I I)f I rt)w
<br /> 1nncJS :wc viowritin por tfq:;cjjh0fj in rj,tb(1,:
<br /> ........... ----—-------
<br /> Representative Name
<br /> Representative's Signature Data
<br /> Toll Free 1-866-896-0600 / wWw-CiWMb.ca.gov,1Tjres/
<br /> whiTe:rNVNAR �tllv C..
<br /> ,7:',
<br />
|