|
California Integrated Waste Management Board
<br /> CA Uniform Waste and Used Tire ManifestPO Box 1259, Sacramento,CA 95812-1259
<br /> :m EXAMPLE111273 AA Manifest Number
<br /> State of California® INSTRUCTIONS ON BACK _ �_ F IV! 1 6 4 3 8 3 Y
<br /> CIWMB 647(03/03) 'TV
<br /> ,?� -m=�;y t� ps �.:...�.° ��^ v> .,..n s,,,-axe :,-,.. r^�+r:.*u,''Yri��;::.s�''�" y n,�,:� t:. ..',.�4'ri.+•«'m<, •,^' fTj�`:�' �.n?:'c�.�Z�.a"`yrs �*t"'�''r °�. �`'''�f`�aiii.�,',"?
<br /> �>x� �I�e¢`` � B ' E�Iaui.�. �' $.. �. a �:. �-� ,� a� a:��,�, .r y � r �r*� f"`�l- fir"?� .i,, • (
<br /> �a..,'C
<br /> o'. �' �` �,, r �� t '� rust ��' '�.,'�,�:�* �� �, ,��?� � t}�✓ a/..i# ,�`rt (. � La-' t
<br /> N�.� §.�"d't�Y��'i� "'�u�tf��n:'�3t�
<br /> ,� k4F' �.ry q'a,,?, 's^ai Wtr 7P+diff' .r _.4 ✓,ni i - - i
<br /> a)4#� tate,704 Hauler's Business Phone , !
<br /> ' �k (IrlClude area code)
<br /> ...,tp�4,,t ,,. ... °u'K.. ...dautc "'1 j __...
<br /> Hauler Exemption (if applicable)
<br /> ❑ Government ❑ LEA Exempt
<br /> ,
<br /> Load Date(MM/DD/YY) Log Number
<br /> ....... _. _ .J AgricultureCommon Carrier/
<br /> i Ba aul
<br /> J j ? Indicate(if applicable)❑ In Transit
<br /> t
<br /> License Plate Number State Decal Number
<br /> ❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret. In
<br /> accordance with Title 14, CCR, Section 17041 et.seq,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 certify 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 /> information 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$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962.
<br /> Driver's Name(print) Driver's Signature Date
<br /> ;�f K;x.,• +Y PYM9+® 1 � ', Mn f& ,��.W t'f, ht � Yr +R"� k f'& �r }=�..L' :!'1f ) $F 1 'u � 3
<br /> E T w� H '}L�I I .. f�1✓ t:lam ' _ � �,—� �1 .,t( f( � _. I t.,. .....�..,..---.-.-r..W.LIjr
<br /> ! 1 4
<br /> Business Name Facility's Business Phone (include area code)
<br /> Number&Street Address
<br /> / e— ❑Address Same As Hauler
<br /> ❑Change Of Address
<br /> _J t
<br /> City _ ~_- _State Zip Code_ _
<br /> Tire Types and Amounts _ v Intended Use
<br /> ❑ Passenger Oversize
<br /> 9 � ❑ Retread/Reuse
<br /> Tire Program ID Site Suffix
<br /> ❑ Recycle
<br /> .`�`; l3s*�'l in 's-<.n�e ' w-r t� z ' '- ! ._.._I �_ 1,.....,_._......._._,_...3 E. i i �_..� j
<br /> ,� ❑Truck El Other
<br /> s k ❑ Fuel
<br /> W, 1--,
<br /> --
<br /> �o�trrr Orbic � lh*r i i
<br /> ( �� ❑ Disposal/Landfill
<br /> 41et�A# OUk1
<br /> Comment Area
<br /> ❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret
<br /> In accordance with Title 14, CCR,Section 17041 et.seq,should any member of the public request disclosure of this information, I request that CIWMB
<br /> contact me at the address and telephone number above.
<br /> I certify 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 /> information 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 /> Representative Name (print) Representative's Signature Date 32876
<br /> Poll Free 1-866-896-0600 / www.ci .ca. ov/Tires/
<br />
|