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Friday, January 07,2005 10:08 AM D Montecino 707449-8943 ^� p 06 T <br /> California Integrated Waste Management Board <br /> . CA Uniform Waste and: Used Tire. Manifest . FFoBox 1269, Sacramento.CA 958'2-1259 ■ <br /> i E X A M PLE 1 2 3 - Manifest Number I <br /> I I I I I I I -1 l i• 1- -I _ !� �( (�� I <br /> State of California M 4 5 5 1 4 5 9 <br /> j awua-s4t(a�) INSTRUCTIONS ON BACK _ V V V <br /> 9 410. <br /> WO <br /> a 1 <br /> .l Business Namel I <br /> _ ROMAN TIRES,INC. f <br /> It <br /> Add, as. 800 LAUREL WOOD ROA[] <br /> l ;y,State,dip SANTA CLARA CA 95054 i <br /> I (408)988-4242 t <br /> - � Rliiik _ ' Hauler s Business Phone - - <br /> (-include area code) <br /> sM _�, <br /> c t L i 7 `-1 Hauler Exemption-(if applicable) <br /> ❑Government❑LIHA Exempt <br /> Load Date(MM/DD/YY) Log Number <br /> r_ _ �.t ❑Agriculture . ❑Common Carrier/ <br /> _ Back Haul 1 <br /> i_ tj�` 1 ( p` _f } l ►- ��E I ' 1 Indicate(it applicable)❑In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidentiality Claim:The information provided In Part I and Part fl 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 regdW disclosure of this information, I request that CIWMB contact <br /> me at the address and telephone nurrrbenabove. <br /> I certify that under penalty of penury under the laws of the Stale of California that the information provided above Is true and corect. In additlon,I am aware that falsification of this <br /> information may result in suspension,revocation,or denial of ranawal of the Waste Tire Hauler Registration pursuanl 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 d"bed in Public Resources Code section 42962. <br /> I <br /> Drivers Name(print Driver's Signature �'' Date I <br /> Business Name /' Facility's Business Phone(includee area&de) I <br /> r <br /> t. `f _�=� <br /> N ber&Street dress � � � �����I� � <br /> If <br /> ❑Address Same As Hauler ! <br /> f � I C]Change Of Address J <br /> _,.L—!_.LI t 1 f ��� E <br /> City State Zip Code <br /> (- Tire Types and Amounts Intended Use <br /> t rL ❑Passenger ❑.Oversize., { ❑Retread/Reuse <br /> l__�f I ` <br /> ire Program ID Site Su Ix I r I (�� I } <br /> 'sky .�' l I ❑Recycle <br /> _ ❑Truck ❑Other ❑Fuel <br /> ER, a s�+�xik , mac { _�T... J ❑Disposal/Landfill <br /> + , T <br /> Cotrrfi7entArea <br /> []Confidentiality Claim:The information provided in Part I and Part it of this form should be considered confidential,proprietary,and/or trade secret. <br /> In accordance with Title 14,CCR,Section 17041 q,sbld any member of the public request -sclosure of this information,I request that CIWMB <br /> contact me at the address and telephone nturtt era ye- <br /> I certify that under penalty of perjury r ttje�ws of the 'to' California that the information provided true an correct.In addition,I am aware that falsification of this i <br /> information may result in civil penalt u o$25,000 da r violation or adarini5irgtiVe penaltiep up t 00 per any per Y.. <br /> described in <br /> Public Resources Code <br /> se M <br /> t = A <br /> & r 1 <br /> esentative Wt lme(prin Re ative' Sign ture Date 32876 ! <br /> Toll Free 1-866-896-0600 / ww.w.dwmb.ca.gov/Tites/ ■ <br /> White-CIWMB Copy Pink:Tire Dealer/Generator/End-Use Facility Copy Yellov.Hauler Copy <br /> FORM NO.W104799-CIWMB A112 16M 222 i87 654,1 <br />