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GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY P.O. BOX 1 / 13000 NEWPORT RD. INVOICE BALLICO, CA 95WME(2W)FV084855 SAN ,304t UIN COUNTY EDT TRIP LOG #: 1003314- 12/01/2006 ENVIRONMENTAL HEALTH DPART DaDT MAN I FEST#: 1003314- 00044965 EA9 DATE DRIVERS INIT RUN# SHIP TO: ACCT#: 6FZBR1 BILL TO: TERMS: NETO GOLDEN BY PRODUCTS BRANNON TIRE 13000 NEWPORT ROAD 3730 N. WILSON WAY BALLICO, CA 95303 STOCKTON, CA 95201 r TPID# HAULER/SHIP VIA: BRANNON TIRE STATE TRUCK#: MISC LIC PLATE#: 9BO9304 DECAL#: HAULER EXEMPTION: EIGOVT F—] LEA EXEMPT COMMON CARRIER ❑AG F—] UNREGISTERED HAULER SPECIAL INSTRUCTIONS: TRAILER: PU DEL TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT DOOR 1.0000 TON 600.00 600.00 TOTAL 600.00 PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENT! 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 amawarethat falsification of this information may 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. Facility epresentative's Name(Print) Facility Representative's Signature Date " 0 CHARGE ❑ PAID CK# WEIGHT CERT 35432 NET WT 15.19 TONS 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 may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code sectioq 42950,and may 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 i Driver's Name(Print),, Driver's Signature Date Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part II,and Part III of this form should be considered o°'c DarQ rt confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure °o of this information,I request that CIWMB contact me at the address and telephone number above. Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required information from this manifest form.