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0 <br /> Waste and Used ,r, 1 S California Integrated Waste Management Board <br /> niform PO Box 1259, Sacramento,CA 95812-1259 <br /> EXAMPLE 1 2 3Manifest Number _ <br /> State of California® INSTRUCTIONS ®N BACK 115. 1 19 15 44J <br /> CI W M B-647(03/03) <br /> 1711 <br /> c. u <br /> fopar nalcdre—as Labe!) <br /> ness Nalmcll <br /> ess <br /> City, State, <br /> ` --- Hauler's Business Phone <br /> kx (include area code) —11 -1i--j. <br /> EHauler Exemption (if applicable) <br /> ElGovernment [:1LEA Exempt <br /> Load Date (MM/DD/YY) Log Numb <br /> er p Agriculture ❑Common Carrier/ <br /> — �_ (_ µ Back Haul <br /> ` L fj, I Indicate if a licable In Transit <br /> C Pp )❑Plate Number State Decal Number <br /> OConfidentiality 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 429^6'}2. } <br /> Driver's Name( rint Driver's Signature Date <br /> f �� .; " -v` �, y� 1 3 l rf °n�'. =ms's <br /> 'Fi 11 <br /> Nal, <br /> f r fit 15 <br /> y" ` n' x� Ail ? <br /> (optional-Address Label) ®1 <br /> F T/ , F1 <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> ❑Address Same As Hauler <br /> ❑Change Of Address <br /> City State Zip Code _ <br /> Tire Types and Amounts - Intended Use <br /> -� ❑ Passenger ❑Oversize ❑Retread/Reuse <br /> Tire Program ID Site Suffix LLJ <br /> i ❑ Recycle <br /> ❑Truck ❑Other ❑ Fuel <br /> LL � I- ❑ Disposal/Landfill <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 /> , J <br /> f <br /> Representative Name(print) Representative's Signature Date 32876 <br /> Toll Free 1-866-696-0600 / w.ci .ca.gov/T6reS/ <br />