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CA Uniform C i.Integ rated Waste Management Board <br /> iform 4-ste and Used Tire Manifl Box 1259, Sacramento,CA 95812-1259 <br /> EXAMPLE FT;'M Manifest Number <br /> state of California M 2 - 18 2 5 7 5 9 <br /> CIWMB-647(10/03) INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE <br /> B,- ing this CA uniform Waste and Used Tire Manifest,the signer(s)requests that the information provided on this form will be considered confidential,proprietary and/or a trade <br /> sIn accordance with Title 14,CCR,Section 17041 et sec.,if a request is made for disclosure of this information,the CIWMB will contact the signer(s)of this form at the address <br /> an. aphone number provided on this manifest. <br /> PARTTO BE COMPLETED BY TIRE HAULER PLEASE PRINT FIRMLY <br /> ,pick Up _Delivery ROMAN TIRES,INC. <br /> 800 Laurelwood Rd. <br /> Please complete if outside California Santa Clara, CA 95054 <br /> (408) 988-4242 <br /> ❑ import/Export Hauler's Business Phone <br /> State/Country (include area code) <br /> Load Date (Mm/DD/YY) Log Number Hauler Exemption(if applicable) <br /> t -J 0 0 []Government EJ LEA Exempt <br /> L 2, E:1 Agriculture []Common Carrier/ <br /> License Plate Number State Decal Number Back Haul <br /> Indicate (if applicable) <br /> 2- 0 El In Transit D Unregistered Hauler <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 perescribed in Public Resources Code section 42962. <br /> 5,1 r 1-/ — 7 — Los-- <br /> Driver's Name(print) Driver's Signatury Date <br /> r T 11: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. <br /> L,___ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF, PLEASE PRINT FIRMLY <br /> BusinessName Facility's Business Phone (include area code) <br /> Tufp QDy ( �_o ? ) P- - I/ / .-3/. <br /> Number &Street Address <br /> A-V E—, <br /> -3 b -7 0 State Zip Code <br /> City F1 Address Same As Hauler <br /> E]Change Of Address <br /> Load Amount <br /> Tire Program ID Site Suffix Load Type (check only one) <br /> Whole Tire Count ❑Weight in Pounds <br /> Volume Cubic Yards rWeight in Tons Whole Numbe s only Decimal <br /> Whole Tire Count__._____-__ <br /> W <br /> ount ------W Passenger Amount Oversize Amount I Intended Use <br /> C - <br /> El Retread/Reuse El Recycle E] Fuel <br /> 113 0 E - .. — -- -- . - . __ — ... <br /> ia Comment Area <br /> C Truck Amount Other Amount <br /> .2 <br /> CL <br /> 0 <br /> 1 certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In a(. ....... <br /> information may result in civil penalties up to$25,000 per day,per violation administrative penalties up to$5,000 per violation per day as described in Public Resources Code <br /> section 42962. <br /> 7'0 <br /> es ntative Name(print) Re)resentative's Signature Date 26187 <br /> ■ Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/"rires/ ® ■ <br /> White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy <br /> 1.Remove top stub 2. Fold in half at fold line 3. Remove adhesive strip 4. Adhere remaining stub <br /> FORM NO.M-104799-CIWMB DO NOT REMOVE THIS STUB M12 9794 519 9 87 S 5 4 3 2 1 <br />