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GOLDEN'BYPRODU&S WASTE & USED TI ANIFEST/RECEIPT 0 1 EDT TRIP LOG#: 1003314- /�_ - } EDT MANIFEST#: 1003314-0 `'� -A DATE DRV INTL RUN# INVOICE# Part 1: Facility Information (Actual physical location of facility) Check one: e PICK UP FROM A GENERATOR ❑ DELIVERY TO AN END USE FACILITY If applicable: ❑Import CExport Imp/Exp Location: NAME: '?�� ',� `.� �,""�� . INC - GOLDEN/STC ACCT#:— — — — — — — ADDRESS: -,l - t i{ TIRE PROGRAM ID: ADDRESS: . '$ `r�?, .�I — — — — — — — CITY,ST,ZIP: E `',;, jc. SITE SUFFIX: <; PHONE: T r� • + a.� f wt TRAILER#: P/U DEL Part 2: Load Information TYPE COUNT RATE DOLLARS uUSEDTIRES Passenger t- @ -S = � oto .9WHOLE WASTE TIRES 9 Intended Use: LIPRODUCT: Tractor 4 @ q� • ❑RETREAD k1WHOLE TIRE COUNT(C) E`RECYCLE uCUBIC YARDS(Y) Other t '� - :_@ I2FUEL !JWEIGHT IN LBS(P) Trailer '+ - 4p@ LA 141&, ❑DISPOSAL LWEIGHT IN TONS(T) TOTAL ..0 1, o:N 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. f f Facility Representative's Name(Print) Facility Representative's Signature /Date ' Part 3: Hauler Information TRUCK#: STATE: CA NAME: Golden By-Products,Inc. ADDRESS: P.O.Box 1 LIC PLATE#: 1'� `) k ADDRESS: 13000 Newport Road - — - — — CITY,ST,ZIP: Ballico,CA 95303 DECAL#: PHONE: (209)668-4855 — — — ❑UNREGISTERED HAULER HAULER EXEMPTION: CGOVT C AG ❑LEA EXEMPT CCOMMON 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 am 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. ode eection 42960 an aresult in civil penalties up to P5,000 per day,per violation or adminis- t ativc pb Yaltieg up to$5,DOA:per violation per day?s described in Public Resources Code section 42962.t ii y i �" yCYCt: i _ ,(`-J �L%t+;- . Driver's Name(Print) Driver's Signature Date ` Part 4: Other Information(Golden By-Products in-house use only) LOG#: L – WEIGHT CERT#: NET WT: TONS _'For the other half of this transaction,hauler is also the: LGenerator End use facility MANIFEST#: M – -B Golden's other half of transaction# !Other EDT Hauler EDT Manifest# IPaper Manifest#in place of Golden EDT Manifest# for: (circle one) Pick-up Delivery ality Claim ion in Part 1,Part 1 and Part I of this form should be red r`c DafQ?rQ d nt all,,proprietary,ary,and/ortrladele to all secret.In accordance with Title 14,CCR,arties listed on above):The ection 17041et seq,should Jany member of the public request disclosure of thisnfi- ON information,I request that CIWMB contact me at the address and telephone number above. W 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. H020404 .