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Friday, January 07,200510:08 AM D Montecino 707449-8943 <br /> California Integrated Waste Management Board <br /> CA Uniform Waste and Used Tire Manifest PO Box 1259, Sacramento,CA 95812-1259 ■ <br /> • jEIX�AjM�Pj�jEj 1112�� �`— Manifest Number <br /> carrornl. INSTRUCTIONS ON BACK <br /> State M5 - 1354 <br /> CIWMB 3!0 85 <br /> CIWMB-6d7(03) �_ <br /> i W'•Fv�� t C I <br /> Haufer (opbora; Address f a el f <br /> Nan Business Ne�T ' <br /> i ROMAN TIRES,INC. <br /> Address 800 LAUREL WOOD BOAC <br /> SANTA CLARA CA 95054 ! <br /> City,Slate,Zip (408)988-4242 <br /> Hauler's Business Phone If <br /> (include area code) L <br /> 1 111 ._J <br /> l } _ Hauler Exemption (d applicable) <br /> ! <br /> [I Government LEA Exempt <br /> Load Date(MM/DD/YY) Log Number <br /> ❑Agriculture ❑Common Carrier/ <br /> I / Back Haul <br /> indicate(if applicable)❑In Transit <br /> jLicense Plate Number State Decal Number <br /> []Confidentiality Claim:The information provided in Part I and Part 11 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,t request that CIWMB contact ; <br /> i me at the address and telephone number above. <br /> l I certify that under penalty of peryury under the laws of the State of California that the information provided above is true and correct. In addition,I am aware that falsjNbaaen 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 per day as described in Public Resources Cotle s n 42 <br /> Driver's Name(nnnt) Driver's Si6naVdre Date <br /> 11117 It.;: TQ 8EOAt 'L t3 SY'REP# ESI ACj CiE TttE' I <br /> i _- �• .T _ - 1Ai 1� � 1E.T. _ i <br /> i ++pt/o al-A ddress bel) <br /> i Business Hart acuity's Business Phone(include areaode) <br /> —/.�� t <br /> —J_'._I I I I I �__.i_ I i ) I I i I ! I I 1 <br /> Number&Street Address <br /> 0 Address Same As Hauler <br /> C Change Of Address <br /> ! t � __ I I I I I t J <br /> i Ci _ _----- -.-_--- _-_State Zip Code <br /> Tire Types and Amounts Intended Use <br /> I I A - ❑Passenger ❑Oversize <br /> _ ❑Retread/Reuse <br /> VIre Program ID Site Su x ! R�y� <br /> ❑Truck <br /> ❑Other Fuel <br /> m0 DisposalA.andfiill <br /> Comment Area <br /> OConfidentiality 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 disclosure of this inform ati request that CIWMB <br /> contact me at the address and telephone number above. <br /> j I Certily that untler penaityd er)ury under the laws of the Stale of California That the information prov ded above is and co R addillon,I 8wars that falsification of this <br /> Intormalion ma uhf'{ it penalties u to$25,000 per day,per violation or administrative <br /> j - Y P P P y P penalties uo per viola' er day a5 nbed In Public Resources Code <br /> ` `sPation 4 <br /> Representative Name(print) Representaix s Signa e -----Date 32e76 <br /> ■ Toll Free 1-866-"6-p W % www.ciwmb-ca.gov/Tires/ ■ <br /> White:CIWM9 Copy Pink:Tire Dea)er/Generator/End-Use Facility Copy Yellow:HaulerCopy <br /> S FORM NO.M-10479C-CIWMd-Aril ise 222 9878l43 <br />