COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

ad f ✓: G'�. • ?�1 -re 3 dx:!0 -Tbl RNSE.HaV 3S11>,DJr a,..1 SRAI- 198 ,r" 2AJS3,A4aV 3Sa4X3P OL RA 21H � ?a CA Uniform Waste and Used Tire Mai est California Integrated Waste Management Board PO Box 1259, Sacramento,CA 95812-1259 Mi-::? EXAMPLE111273 Manifest Number C,WMState -647(10/0 INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE M 1 - 18 2 5 l 8 2 CIW MB-647(10/03) r ging 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 - In accordance with Title 14,CCR,Section 17041 et seq.,if a request is made for disclosure of this information,the CIW MB will contact the signer(s)of this form at the address and telephone number provided on this manifest. — --- --- -- — ---- -- - --- - -- -- ----- - -- -- -- --- — �PART I —TO OBE COMPLETED- BY TIRE HAULER PLEASE PRINT FIRMLYI - - - - - — --- ROMAN FIRES,EW. /JFPick Up I _-]Delivery 800 Laurelwood Rd. Santa Clara, CA 95054 Please complete if outside California (408)988-4242 ❑ Import/Export Hauler's Business Phone State/Country (include area code) Load Date (MM/DD/YY) Log Number Hauler Exemption(if applicable) +1 �^� / 1 / n [ L( O D 2 [:1 Government EJ LEA Exempt It U U ❑Agriculture ❑ Common Carrier/ License Plate Number State Decal Number Back Haul 4 _ � Indicate (if applicable) 11 /n ( O ❑ In Transit ❑ Unregistered Hauler 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 information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Publi sources Code section 42960 and 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 des crib ub/li Resources Code section 42962. Driver's Name(print) Driver's Signature Date PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY. USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPEDOFF. _ PLEASE PRINT FIRMLY Business Name TV 1 t (2 oy. 5 4L QS/ �— - Facility's Business Phone (include area code) Number & Street Address ZI ti City State Zip Code ❑Address Same As Hauler ❑Change Of Address Tire Program ID Site Suffix Load Type (check only one) Load AmountI✓ - / ❑Whole Tire Count ❑Weight in Pounds / ❑ Volume Cubic Yards❑ Weight in Tons Whole Numbers only Decimal for Whole Tire Count Passenger Amount Oversize Amount Intended Use � GC • ❑ Retread/Reuse ❑ Recycle ❑ Ft. f --- ...__.... .._ --- -. �p M cC ■ ■ Comment Area 0 Truck Amount Other Amount l p a,� O ■ ■ 1 certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.lir auumun,i am aware mat taisitication of this infr 'ion may result in civil penalties up to$25,000 per day,per violation orainistrative penalties up to$5,000 per violation per day as described in Public Resoufces C de se 12962. , 4—M L <� M Repre ntative Name(print) Y Representative I s Signature Date 26187 ® Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/rires/ White:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow:Hauler Copy NEE]