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-i-PRODS WASTE & USED T11A ANIFEST/RECEIPT EDT TRIP LOG 1003314- DATE DRV INTL RUN#_ INVOICE# T TRIP 2 , 0 F -A EDT MANIFEST#: 1003314-010)2 /2 0 7 Part 1: Facility Information (Actual physical location of facility) Check one: R'PICK UP FROM A GENERATOR 0 DELIVERY TO AN END USE FACILITY If applicable: Olmport OExport Imp/Exp Location: NAME- GOLDEN/STC ACCT#: ADDRESS: ADDRESS: /'vl TIRE PROGRAM ID: CITY,ST,ZIP: SITE SUFFIX: PHONE: TRAILER#: P/U DEL Part 2: Load Information TYPE COUNT RATE DOLLARS AUSED TIRES D WHOLE WASTE TIRES Passenger @ Truck Intended Use: EIPRODUCT: @ Tractor �_ o ORETREAD AWHOLE TIRE COUNT(C) Other D r! .0RECYCLE @ OCUBIC YARDS(Y) --/-( 2FUEL OWEIGHT IN LBS(P) Trailer @ OWEIGHT IN TONS(T) TOTAL ✓ ODISPOSAL 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#: STATE: CA NAME: Golden By-Products,Inc. Ct Ct ADDRESS: P.O.Box I LIC PLATE#: ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 -D=-#: PHONE: (209)6684855 S T — — — — — — — - HAULER EXEMPTION: OGOVT El AG OLEA EXEMPT OCOMMON CARRIER D0 UNREGISTERED HAULER RIVER'S LIC#: I certify that under penalty of perjuryunder 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 Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or adminis- 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 Date Part 4: Other Information(Golden By-Products in-house use only) AUTHORIZATION BY LOG#:L— - — — — — — — — WEIGHT CERT#: NET WT: TONS ] E]For the other half of this transaction,hauler is also the: 0 Generator End use facility MANIFEST#:M - — — — — — — — — — — — — — — — — — — — — — — — — Golden's other half of transaction# L Other EDT Hauler EDT Manifest# 1-Taper Manifest#in place ofGoldens EDT Manifest# for (circle one) Pic Data Confidentiality Claim(applicable to all parties listed on above):The information provided in Part 1,Part 11 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. Electronid 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. 1(100404