Laserfiche WebLink
Friday,January 07, 2005 10 08 AM D Montecino 707449-8943 p.08 <br /> Cal funic In�.egreted Waste Management Scard I <br /> 1 _: CA Uniform Waste land Used.Tire Manifest ppBox ,259. Sacramento,CAP95812-1259 <br /> • �_ IE{X AIM,PjLIEj 11.12131 Manifest Number <br /> $lit9 0tC8tItORrls � k M 9 - 13 5 4 5 8 3 <br /> ciwPA}647(03f03) INSTRUCTIONS ON BACK <br /> KNOMI <br /> wafer (optional—Address Label}:. l <br /> Business Name <br /> addr-ess ROMAN TIRES,INC. <br /> ,Zi .800 Laurelwood Rd. ! <br /> City,Stan=., p Seth Clara,CA 95054 <br /> a <br /> — Hauler's Business Phone _ <br /> (include area code) <br /> {�,'',jam- /l►/t 7C( Hauler Exemption (if applicable) <br /> v ❑Government❑LEA Exempt <br /> i <br /> Load Date (MM/DDNY) <br /> Log Number ❑Agriculture ❑Common Carrier/ <br /> F61 <br /> �/ 7 ( IBack Haul <br /> 0i.G if l � �� Indicate(11 aPRlicabte)❑In Transit <br /> i .( f <br /> Li se Plate Number State Decal Number <br /> ❑Confidentiality Claim:The information provided in Part I and Part Il 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,I request that CtWMB bOnlaCt i <br /> me at the address and telephone number above.' I <br /> i I certify that under penalty of penury under the taws of the State of Caliiomia 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_p�uam 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 day99 y o r In Public Resources Code section 42962: i <br /> ' Nam nnE <br /> Driver's Si nature ,% Date <br /> Drivers.. .. .. .: 7.,,.. . <br /> I (optional-Address - <br /> �1`: <br /> Business Nartife- <br /> Facility`s Business Phone(include area code) i <br /> i <br /> L-1-15 j i_ L II orI I I t I I I i t I I ,j <br /> -„Number&Street Address I <br /> �¢` �/ �j /� J _ ❑Address Same r s Hauler <br /> f'---rjtj L--t-- I I l^J Change OI Address i <br /> City tate Zip Code _ <br /> Tire Types and Amounts Intended Use <br /> C3 Passenger ❑Oversize ❑Retread/Reuse <br /> Ire Program ID Site Suffix { ❑Recycle. <br /> Truck O other ❑Fuel <br /> I I r <br /> x' r ) ❑Disposal/Landfill <br /> �- 'Comment Area <br /> i~ ❑Confidentiality Claim:The information provided in Part'and Part Ilfrif 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 information,I request that CIW MB <br /> contact 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 informations provid beve fie is and co .Ina on,I am aware that talslficetien of this i <br /> t informtion may result in civil penalties up to$25,000 perday7pervieletiea a penalties u o�S;dt30 per viol per nbed in Public Resources Code <br /> i <br /> :-:T <br /> i Son-47v <br /> t 4 <br /> i. Representative Name(print) -- "1=tepresenta e's Signa ut re Date 32876 . <br /> Toll Free 1-866-896-0600 / www.CiwMb.Ca.gov/rires/ <br /> White;CIWMB Copy Pink:Tire DeatedGenelator/End-Use Fatality Copy Vellow.Hauler Copy <br /> r„” FOnM NO-M•104199-MMa Mia•am va¢4B9{fae r <br />