Laserfiche WebLink
Friday,January 07,2005 10 08 AM <br /> D Montecino 707449-8943 <br /> California Integrated Waste Management Board <br /> ■ CA Unifoirm.Waste and Used Tire Manifest AOBolt,269, Sacramento,CA 95812-1259 ■ <br /> Manifest Number <br /> LE1x1sJMJ0J*L•GE.I 11-12131 M- 3.- <br /> ' <br /> State CIWM ofCaliforniaTIONS ON BACK IW- v 1 J 5 2 70 v <br /> CIWMB-all(0103)- <br /> INSTRUCTIONS <br /> fi Hauler. (aptionaJ Acidress•Label) <br /> Business Nam ROMANI <br /> DBEs,INC. <br /> Address 800'Upretwood Rd. . . <br /> City, State,Zip Santa.C14M.CA-95054 <br /> L (408)988-4242 _l <br /> _ A - Haulers Business Phone <br /> 1 (include area code) _L-_! - J. <br /> r <br /> f i 1 f ' �' t Hauler Exemption (if applicable) <br /> f L ❑ P <br /> lJ ❑Government LEA Exempt <br /> ! k] <br /> Load Date(MM/DD/YY) Lop Number <br /> ❑Agriculture ❑Common Carrier/ <br /> r <br /> i Back Haut <br /> K1 \ f ' ' Indicate(if applicable)❑In Transit <br /> License Plate Number State Decal Number <br /> ❑Confidentiality Claim:The information provided in Pan 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,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 Calilomia that the information provided above is true and correct. In addition,I am aware that falsification of this <br /> j information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code���eeection 42F60 and may result in civil <br /> penalties up to$25.o levier clay,per\notation or administrative penalties up to$5,000 per violation per day as described In Public Resources Co section <br /> 7r/ <br /> Driver's Name rind Driver's Sig ifture Date <br /> i3Tti4tyE <br /> or.`� A9f, $ t1i01411v_ <br /> i ioA1:Wrtt�RF. -5 pE kCeD <br /> uR o#' <br /> I-... 7( 6nal-Acak*_es�Labe) <br /> Business erne <br /> 014➢tity's'Btusfness hone-(include area code) <br /> Number&Street Address <br /> Address Same As Hauler <br /> 171 I t I I t L�� �• I E]Change Of Address <br /> city tate Zip Code <br /> Tire Types and Amounts — Intended Use <br /> �J} j , 14 1 �_ -! f / 1 OPas-senger _ ❑Oversize I ❑Retread/Reuse <br /> Tire Program ID Site Suffix i i {f <br /> -� I ❑Recycle <br /> = tKTruck ❑Other ,1111 <br /> 0 Fuel <br /> I• i`�posa►/Landtin <br /> I Comment Area <br /> t nfidentiality Claim: The information provided in Part I and Part 11 of this form should be considered confidential,proprietary,and/or trade secret. <br /> In accordance with Title 14,CCR,Seco s ou ny member of the public request d" sure of this information,I request that CIWMB <br /> icontact me at the addre and tel one nu r oye. <br /> I certify that under penalty of rder th of ate Calif is that the information pr dad s true and correct.In addition,I am aware that falsification of this <br /> tnroray result in ci ' hes up 25,0 per Ps inistrative aftles 000 per violation per day as describedin Publ Resources Coda <br /> I � <br /> mese tive Narr,print) C—Ue�r Sentative's Signature Date <br /> i � 32876 <br /> ■ Toll Free 1-866-896-0600 / www.Ciwmb.Mgov/Tires/ r - �j ■ <br /> } White:CIWMB Copy Pink:Tire Dsaler/Generator/End-Use Facility Copy Yellow:Hauler Copy <br /> i - <br /> FORM NO.M-10479*gMMIe M+2,sw Zit 9 D r8 5.p <br />