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GOLDEN BY PROD CTS WASTE & USED TA MANIFEST/RECEIPT EDT TRIP LOG#: 1003314- /{%/(�-, -- - (..- - ' L ' fx EDT MANIFEST#: 1003314-0 ® -A L DATE DRV INTL RUN# INVOICE# Part 1: Facili • Information (Actual physical location of facility) Check one: X PICK UP FROM A GENERATOR ❑ DELIVERY TO AN END USE FACILITY If applicable: I LImport ❑Export Imp/Exp Location: GOLDEN/STC ACCT#: NAME: ;s",�/,�� z�'' ��,T /%'M`+?,�''��„e' �,`�r�if r.^'. ADDRESS: TIRE PROGRAM ID: ADDRESS: .:5'��ai "' "'Cs — CITY,ST,ZIP: �,f ,,, df��fX_ SITE SUFFIX: — — PHONE: TRAILER#: P/U DEL Part 2: Load Information TYPE COUNT RATE DOLLARS !JUSED TIRES Passenger " (WHOLE WASTE TIRES g @ Intended Use: I�' � Truck - UPRODUCT: @ ❑RETREAD Tractor - E )(1 WHOLE TIRE COUNT(C) Other �SI�RECYCLE @ _ .FUEL LI CUBIC YARDS(Y) Trailer @ = J" ❑DISPOSAL U WEIGHT IN LBS(P) U WEIGHT IN TONS(T) TOTAL 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 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 Representative's Name(Print) Facility Representative's Signature Date Part 3: Hauler Information TRUCK#: — tom''` STATE: CA NAME: Golden By-Products,Inc. , ADDRESS: P.O.Box I LIC PLATE#: 'r ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 5/03 DECAL#:, PHONE: (209)668-4855 ❑UNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT ❑ AG RLEA EXEMPT ❑COMMON CARRIER DRIVER'S LIC#: 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 ani aware that falsification of this information may result in sus- pension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or adrfiinis- trative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. Driver's Name(Print) Driver's Signature. Part 4: Other Information(Golden BY-Products in-house use only) LOG#:L — WEIGHT CERT#: NET WT: agog 11 For the other half of this transaction,hauler is also the: UGenerator UEnd use Facili MANIFEST#:M ,Golden's other half of transaction# iOther EDT Hauler EDT Manifest# IPaper Manifest#in place of Goldens EDT Manifest# for: (circle one) Pick-up Delivery Datq 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 confi- dential,proprietary,and/or trade secret.In 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 me at the address and telephone number above. U3 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.