Laserfiche WebLink
;._ --- -------- ­`UU tfox 12b9, Sacramento,CA 95812-1259 <br /> E X lA jM P I i ill <br /> ;, Manifest Number <br /> State of California "I a - 0 2 <br /> ctwrme-sa7(loioa) INSTRUCTIONS ON BACK,-_ �O NOT TAPE. STAPLE OR DUPLICATE )ff}�jj i',j} Lj <br /> By signing 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 /> secret. In accordance with Title 14,CCR.Section 17041 et seq.,if a request is made for disclosure of this information,the CIWMB will contact the signer(s)of this form at the address <br /> and telephone number provided on this manitest. <br /> RT l , TO BE COMPLETED BY TIRE HAULER <br /> PLEASE PRtNT FIRMLY <br /> Hauler <br /> Pick Up Delivery ROMAN TI S,INC. <br /> Business Name 800 Laurclwood Rd. <br /> Please complete if;outside.California Address Santa Mara, CA 95054 <br /> City, State, Zip (408) 988-4242 <br /> ❑ lmport/Export <br /> Hauler's Business Phone <br /> State/Country (include area code) <br /> Load Date (MM/DD/YY) Log Number / Hauler Exemption(If applicable) <br /> A(J 1 / �"' _ 1? .i h? - ❑ Government [J LEA Exempt <br /> j �.) .� ;. <br /> `" ❑ Agriculture ❑ Common Carrier/ <br /> License Plate Number State Decal Number Back Haul <br /> �._ <br /> Indicate (if applicable) <br /> JJ.- <br /> f 0 L' - ❑ In Transit ❑ 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 pursuan;,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,des bedlin Public Resources Code section 42962. <br /> Driver s Name(print) Driver's Signature Date <br /> f% <br /> `RT II; TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE FACILITY, <br /> .E AGTIl LOCATION WHERE THE,TIRES ARE PICKED-UP OR DROPPED OFF. PLEASE PRINT FIRMLY <br /> Business Name Facility's Business Phone (include sarea code) <br /> Number & Str et Address <br /> City State Zip Code <br /> Address Same As Hauler <br /> ❑ Change Of Address <br /> Tire Program ID Site Suffix Load Type (check oniy.one) Load Amount <br /> Whole Tire Count F-] Weight in Pounds <br /> Volume Cubic Yards❑Weight in Tons Whole I UmKerS only • `Decimal <br /> for Whole Tire Count <br /> Passenger Amount Oversize Amount Intended Use <br /> Rf <br /> Q ❑ Retread/Reuse ❑ Recycle ❑ Fuel ❑ Disposal/Landfill <br /> Comment Area <br /> Co Truck Amount Other Amount <br /> CL <br /> ■ ■ <br /> I certify that under gena y of periury under the laws of the State of California that the inf ation provided above is true and correct.In addition,I am aware that falsification of this <br /> information may reqult civil penalties up to 525,000 per day�per- ic�latio,or acts ve penalties to$5.000 per violation.per day as described in Public Resources Code <br /> '-seotion 4296. J <br /> r.epresentative Name(print) Representative's Signature Date 26187 <br /> Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/rires/ �■ J <br /> a rk White:CIWMB Copy Pink.Tire DealerlGenerator/End Use Facility Copy Yellow:Hauler Copy �7-J <br /> x <br /> -® <br /> 1.Remo ve top stub 2. Fold in half at fold line 3. Remove adhesive strip 4. Adhere remaining stub <br /> > w <br />