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California Integrated Waste Management Board <br /> CA Uniform Waste and Used ,r Manifest PO Box 1259 Sacramento CA 95812-1259 <br /> EXAMPLE 1 2 3 Manifest Number <br /> State of California® INSTRUCTI®NS®N BACK . 1 19 15 3S <br /> CIWMB 647(03!03) �* <br /> Sri <br /> Ad✓dess Label) <br /> x <br /> Cily, State, Zip <br /> Hauler's Business Phone i <br /> (include area code) <br /> { T / / i 4i L.i � r x (if applicable) <br /> { ( } Haute Exemption j �—' ❑ Government ❑ LEA Exempt <br /> Load Date (MM/DD/YY) Log Number <br /> . _ ; __�___ 1 _ ____ ❑ culture Common Carrier/ <br /> + � Agri r <br /> a <br /> Back Haul <br /> liz <br /> fIndicate(if applicable)❑ In Transit <br /> _ <br /> License Plate Number State _Decal Number <br /> ^Monfidentiality 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.flie,address and telephone number above: <br /> W <br /> I certify hk 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 /> informafl ft 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 /> t <br /> Driver's Name(print) Driver's Signature Date <br /> .` <br /> Business Name Facility's Business Phone (include area code) <br /> I <br /> Number&Street Address <br /> � y f-1 Address Same As Hauler <br /> E] 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 =-= I I I I I'�—u El Recycle <br /> ❑Truck ❑Other ❑ Fuel <br /> h X <br /> ❑ Disposal/Landfill <br /> Comment Area <br /> pConfidentiality 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 /> Toll Free 1-866-896-0600 / .Ci mb.ca. ov1Tires/ <br />