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­ — 0 Is 10 ____ ­__ <br /> 0 -_ ­­ - ____ - __ <br /> GOLDEN BY-PRODUCTS dba SCRAP T E COMPANY <br /> P.O. BOX 1 / 13 9MWP(% ��. <br /> BALLICO, CA 951 � JUNVOICE <br /> �� bHfi u <br /> yEALT" <br /> EDT TRIP LOG#: 1003314- 12/01/2006 EDT MANIFEST#: 1003314- 00044969 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT#: 6FZBR1 BILL TO: TERMS: NETO <br /> GOLDEN BY PRODUCTS BRANNON TIRE <br /> 13000 NEWPORT ROAD 3730 N. WILSON WAY <br /> BALLICO, CA 95303 STOCKTON, CA 95201 <br /> TPID# <br /> HAULER/SHIP VIA: BRANNON TIRE STATE <br /> TRUCK#: MISC LIC PLATE#: 9B09304 DECAL#: <br /> HAULER EXEMPTION: <br /> F]GOVT r—] LEA EXEMPT F—] COMMON CARRIER F-1 AG ❑ UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER:. PU DEL <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> DOOR 1.0000 TON 600.00 600.00 <br /> TOTAL 600.00 <br /> PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENTI <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 information <br /> may <br /> result in civil 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 Code section 42962. <br /> Facility Representative's Name(Print) Facility Representative's Signature Date <br /> CHARGE 7 PAID CK# <br /> WEIGHT CERT 35444 NET WT 10.62 TONS <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 information <br /> may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42950 and may result in civil penalties up to <br /> $25,000 per day per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> x x <br /> Driver's Name(Print) Driver's Signature Date <br /> Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part ll,and Part III of this form should be considered <br /> roc Datp confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> .moo `rP of this information,I request that CIWMB contact me at the address and telephone number above. <br /> Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT <br /> electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required <br />