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California Integrated Waste Management Board
<br /> CAUniform Waste and Used Tire ManifestPO Box 1259, Sacramento,CA 95812-1259
<br /> EXAMPLE 12 3
<br /> IMI 7_Manifest Number
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<br /> 6 3
<br /> State of California
<br /> CIWMB 647(03/03) INSTRUCTIONS ON BACK ■
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<br /> UJ. -iter' es & Service
<br /> � ��� � 4 6530 Franklin Blvd.
<br /> Sacramento, CA 9523
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<br /> Hauler's Business Phone
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<br /> area co
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<br /> Hauler Exemption (if applicable)
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<br /> El Government El LEA Exempt
<br /> Load DateMM/DD/YY Log Number
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<br /> ( ) ❑Agriculture ❑ Common Carrier/
<br /> --
<br /> I i ) Back Haul
<br /> Indicate(if applicable)❑ In Transit
<br /> License Plate Number State _ Dec_al Number
<br /> ❑Confidentiality Claim: The information provided in Part Iand 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 perviolation per day as described in Public Resources Code section 42962.
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<br /> Driver's Name(print) Driver's Signature Date
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<br /> Business Name Facility' Business Phone (include area code)
<br /> Number&Street Address i
<br /> Hauler
<br /> E]Change Of Address
<br /> City State Zip Code
<br /> I - -- -- _�- Tire Types and Amounts Intended Use
<br /> ❑ Passenger ❑Oversize ❑ Retread/Reuse
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<br /> Tire Program ID Site SuffixW. IEl Recyclepaw
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<br /> EDfruck ❑Other ❑ Fuel
<br /> Mate GettCt _ - �' i ( i ; ❑ Disposal/Landfill
<br /> Comment Area I
<br /> S 4,y
<br /> Confidentiality Claim: The information provided in Part I and Part Il of this form should be considered confidential,proprietary,and/or trade secr,�.
<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 /> II Free 1-866-896-0600 / www.Ciwmb.ca.gov/Tires/
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