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Friday,January 07,200510:08 AM D Montecino 707449-8943 <br /> CA Uniform.Waste. and Used Tire Manifest CaPOBo 1259,Sacramento,CA 95012-1259 i <br /> i _ Manifest Number j <br /> ■ E XIAIA0 LIE( 1112131 - ) <br /> State of California #� 135226, 2 <br /> I c1WMB-647!031031 INSTRUCTIONS ON BACK M <br /> �(Oj'71lO � :1 G'c1 rCSS Label) ' <br /> Susjness Name <br /> i ROMAN TIRES,INC. j <br /> Address g00 Laumlwood Rd. <br /> City,State,Zip Santa Clara,CA 95054 j <br /> 1408)988-4242 <br /> r <br /> Hauler's Business Phone f l <br /> (include area code) ( L.� - i <br /> F/71 / f1 i Hauler Exemption (if applicable), ! ❑Government ❑LEA Exempt <br /> I <br /> Looa9d Date(MLVDDNY) Log Number 1 } p Agricuhure El Common Carrier/ i <br /> �i/ � �� Back Haul i <br /> ! ! Indicate(if applicable)0 in Transit <br /> License Plate Number _ Stata Decal Number <br /> I ❑Confidentiality Claim:The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret.In <br /> I 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 dental of renewdl of the Waste Tire Hauler Registration punt ublic 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 viotabcn per day as d r' m Public Resources Code section 42962. <br /> Driver's ame rint) Driver's Si mature Date <br /> o tonal-Ad�ress Label: <br /> 1 I - 1 f7—�q� <br /> Business Nam Facility's Business Phone(include area code) <br /> 33 <br /> umber&Street Address <br /> ji !/ fir/ �• (//'�U / ❑Address Same As Hader <br /> I�)` r �! L r - i "I 1 ---( L t {. I I L I t ❑Change Of Address <br /> City - - - -- _State Zip-Code --- ---- <br /> j Tire Types and Amounts Intended Use <br /> [3Passenger ❑Oversize ` He!read/Reuse <br /> Tire Program ID Site Suffix { [I! ,i� <br /> t �►� ❑Recycle <br /> ❑Truck [1 Other 0 Fuel <br /> • I � ❑DisposaVLandfill <br /> Comment Area <br /> ❑Confidentiality 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 dlsC a of this information,t request that CIWMB <br /> contact me at the address and telephone number above. i <br /> i <br /> ! 1 certify that under pe ty iv perjury under the laws of the State of California that the information pr ov S cru rid correct.In addition,I am aware that falsification of this <br /> Il information mays esu in civil penal-s up to$25,0007ar violation or administralitfe pen up to ,000 r violation per day as described in Public Resources Code <br /> Representative Name(print) C Representative's Sidature Date 32876 <br /> ■ Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ ■�.J ■ <br /> Whim:CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellow.Hauler Copy <br /> FORMNO M•104799-CIWMB Mix+sto m 5076543 <br />