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MAY-31-2005 06:46 CITY OF MANTECA 2098252343 P.02i02 <br /> a5romla Integrated W.rvte Management Goarn7 <br /> CA <br /> Uniform W� a and Used Tire ManifesoPo Mi.1259. Sacavrento.CA 958121259 <br /> ___=• � Manifest Number <br /> EXAMPJLJEJ J1122 �A <br /> scam of cafllomrB I t <br /> - I � <br /> CMUS.ea7fo i) INSTRUCTIONS ON BACK fYl 1 .. 6 9_3 aY��f_ <br /> .,4`•"1' 'lr•^l'r ,` - rc r < R! 1 ry c.1'. 1;T�+ }Ijt?'� r�17^1r'P+Y(t.IIH�7^t'�Y-it,r t'';a t4�ra x'r',�y —IF. SC "Y" ra <br /> •r i 7 <br /> �"P" ��ar'L..,'��y�fi�,1�.�" � �. ^!�tii`:L��'���G�t..: a�l•:elht��l i}� � a�� �..a't;5i <br /> Ff tblAh .S a 9M� ,, <br /> .i,._ <br /> Ll tt.r_. .^x.rG� oJ... amort <br /> �..�"'�a "�.'�tiahis �_,• � � �.7. i/ /'- -!'"�j/ + . <br /> rw Slata $,? Pa1.:il:' LLQ- �--. / 7 ' r�Yf.' ...4 ��• . <br /> P. <br /> Firs,Wit✓ ) _ _ r i.• ), - ' <br /> ar'Hauters Business Phone I_ • -77— <br /> Y <br /> _. �y <br /> (include.area code)' <br /> f Jib>i'• t 'ii I�7;.1-:J,ry.a _ ___ max.._ _ _ =� _ _ <br /> Hauler Exemption (it applicable) <br /> L �i //f , ,.�X .� I;� ; ❑Government[I LEA Exempt <br /> Loa Date(MM/DD/YY) Log Plumber ❑Agriculture.'C1 Common Carried <br /> .T _ {t�^--- l+�" Y- 13ack Haul, <br /> / '^ 1 'moi; t i .�, r r •'�tt i I .f <br /> i j Indicate(if applicable)0 In Transit <br /> License Plate Number State_. Decal Number' <br /> OConfidentiality Claim:The information provided impart f and.Pari ll of,this form should be considered confidential.proprietary,and/or trade secret..In <br /> accordance with Title 14,CCR,Section 17041 eLseq.should any member of the public request disclosure of this information,I request that CIWMB contact <br /> me at the address and telephone number above. -. <br /> I certiiyf that under penalty of perjury under the laves of the State of Catifomia that the Information provlrl?d above is true,-and Correct. in addition,f am aware that falsification of this <br /> information may rosu4 in suspension.rP.voCatfon-or dental of renewal of me Waste Tire Mauler Registration pursuant to Public Resource;Code section 42969 and may result in CMI <br /> p4nVile-s up to S25.000 per day,per violation or administrative penalties up to$5.000 per v:olstion J 3ey as W3Ecribad fAAublir gesources Code Section 42962 <br /> Driver's Nama rint "_sS1ure Date <br /> <' ^1„ ,.Y,„�'• f 7 I yi Q 4tC4 .':Sxtf= -' Palr <br /> r <br /> Business Name Facility's Business Phone(include area code) <br /> r <br /> NIilmber&StreetAddress <br /> ❑Addre-ss Same As Hauler <br /> ChEwge Of AddrgGs <br /> City Ste <br /> n atUse <br /> State <br /> Ip ode <br /> e <br /> l Types and Amounts <br /> Passenger . <]Oversize „ �) Retread/Rouse <br /> -Tire Program 10---- ---Site Suffix - <br /> I i © Recycle <br /> r ❑Truck.' ❑Other ❑Fuel <br /> I� I •t I ❑DisposaVLandfill <br /> Comment Area <br /> _-- <br /> ❑Confidentiality Claim: The informaiion provided in Part i and Part it of Mis•form should be considered confidential.proprietary.andior trade secret. <br /> In accordance with Title 14.CCR.Section 17041 et.seq,should any member of Aho public request-.disclosure of this information, I request that CIWMG <br /> contact me at the address and telephone rumber above. <br /> I certify mat under penalty of perjury uw*r the laws of 1116$Tare of,Cariiornia that the infomia.ion provided-above is true and cored.In addition,1 a,n rware that lafst0cation of Utls <br /> informa[i0C may resu ip Civ:-1pP all UP to$2S.000 per day,for violation or edministralive penalties up to 55.000 Per violation per day ras describuveJ iq Public Rr=vrces Corte <br /> section 82962Y <br /> Representative Name(print) Representative's Signature Date 32876 <br /> TOTAL P.02 <br />