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CA Uniformand Used Tire Manife California Integrated Waste Management Board <br /> L..gPO Box 1259, Sacramento,CA 95812-1259 <br /> ^_)eEXAMPLE 2 Manifest Number <br /> ciWMaCalifornia) <br /> (10/03) INSTRUCTIONS ON BACK DO NOT TAPE STAPLE OR DUPLICATE M ' - 2 a 5 2 0 5 6 <br /> By signing this CA Uniform Waste and Used Tire Manifest,the signer(s)requests that the information provided on this form will be considered confidential,proprietary and/or a trade <br /> secret. In accordance with Title 14,CCR,Section 17041 et seq.,if a request is made for disclosure of this information,the CIWMB will contact the signer(s)of this form at the address <br /> and telephone number provided on this manifest. <br /> PART I: TO BE COMPLETED BY TIRE HAULER _ PLEASE PRINT FIRMLY <br /> dick Up Delivery C'C Jc•1^ C N CK <br /> Please complete if outside California -� (!%CIe-- <br /> ❑ Import/Export LA <br /> State/Count Hauler's Business Phone <br /> State/Country (include area code) ( � C) 'L1„ 1 f'`. ! , (��_ /•� � �,,^\ <br /> Load Date (MM/DD/YY) Log Number \ / Hauler Exemption(;t applicable) <br /> r I �' I _ I ,•� C� El Government ❑ LEA Exempt <br /> License Plate Number 1— (� ❑ Agriculture El Common Carrier/ <br /> State Decal Number Back Haul <br /> T z c) 0 _ 1 / IIndicate (if applicable) <br /> (� [�diTransit ❑ Unregistered Hauler <br /> =11ty that under penalty of perjury under the laws of the State of California that the information provided above is true and correct. In addition,I am aware that falsification of this <br /> ntcrmahon may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil <br /> penalties up to 525.000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> t. <br /> Driver's Name(print) Driver's ignature Date <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. <br /> USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. PLEASE PRINT FIRMLY <br /> Business Name Facility's Business Phone (include area code) <br /> Number & Street Address I <br /> City <br /> State Zip Code <br /> Cl j j ❑Address Same As Hauler <br /> C, J�� <br /> ❑Change Of Address <br /> Tire Program ID Site Suffix Lo Type (check only one) Load Amount <br /> Whole Tire Count ❑Weight in Pounds <br /> Volume Cubic Yards❑Weight in Tons Whole Numbers only Decimal <br /> Passenger Amount Oversize Amount Intended Use for Whole Tire Count <br /> co <br /> 0 ❑ Retread/Reuse <br /> El Recycle El Fuel ❑ Disposal/Landfill <br /> co <br /> O Truck Amount Other Amount Comment Area <br /> O <br /> 0- <br /> 0 O <br /> I Celt fy that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware that falsification of this <br /> ^,lo-mation may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. / <br /> L4Citi z C <br /> Representati a Name(print) Repr senta s Signature■ Date 26187 <br /> Toll Free 1-866-896-0600 / www.ciwmb.ca.govlTires/ <br /> White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy <br />