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JUL 30 2004 11 : 39AM HE LASERJET 3200 p. 7 <br /> WASTE & USEDITIRE MANIFESURECEIPT <br /> Z. <br /> T TRIP'LOCx#: 10033114-1-1/Us— <br /> EDT MANIFEST#: 1003314-•" -A <br /> DDRV WM RUN ff INVOICE t+ <br /> Part It Eacilitv,Information (Actual physical location of facility) <br /> Check one: ❑ PICK UP FROM A GENERATOR 0 DELIVERY TO AN ENDUSE FACILITY <br /> If applicable: ~ 01inpon 0Export Imp/Exp Location: <br /> GOLDEN/STC ACC'T#: <br /> NAME: Golden By-Products,Inc. —— — <br /> A1jDRES3c P.O.Box I TIRE PROGRAM ICS: 1003314 <br /> ADDRESS.- 13000 Newport Road <br /> CITY,.ST,ZIP: Ballico;CA. 95303 SITE SUFFIX: 01 <br /> PHONE: : (209)668-4855 <br /> TRAMER#: P/U DEL. <br /> _:Part 2 Loi>Information T PE . COUNT RATE DOLLARS <br /> "USED TIRES Passenger . <br /> awHOL WASTE I ES Intended use: <br /> Truck .: <br /> flPROT?UCT TractlJl ORE AD <br /> 0WHOLE Tri COUNr:(c7 — YC E <br /> acUBIC YARDS(Y) tither , e j <br /> 0 WEIGHT IN LBS(P) Trailer = CiD1SPOSAL.. <br /> OWEIGH' ONS(T) TOTAL' <br /> I'COM thetunder Itypf periu the tans ofthe,6lata a(UIfoink ihat#w Irdamlafon pnovWedebove4a true and oafIrgeddktdd I n awareftGt of thle Informed 'ray reauN in dvA <br /> psnapios 013 t* floc p� clay, ationor,A a pana8ias up tam t psr viohtion pw dayas elowrfsd n Pub �burcaa saCtlon 422: <br /> -ility R ve's Name(Print) . FaeilitgRepfYsentiave's`SY�S•aturepate <br /> ' Part 3: I��Ier Inf©rma8is�n � <br /> TRITCIC'.#: S7PATE <br /> �,- <br /> ADI3RESS # LIC PLATE05 <br /> AnnRsss• � ! <br /> CITY,ST,.2TP: DECAI,# <br /> 11 f 1 EUNREGISTE1tED HAULER <br /> HAULER-EXEMPTION.- CGOVT ❑ AG CILEA EXEMPT I OMMONC DRIVER'S LIC#: <br /> I oertlfy that under penahy of pe*"under fa taus ofthe Smte of,Caftfomta dtetthe Infomtaffon p;cwldad attOW s tttt)t'am correct)Adaffen,I sm 4hat fo cation ofthis infomuNian may result In sus- <br /> pension,revocation,or deriel of. of dw WW*Tire Hauler Aegistmtion pumuotto Publia Resouro�Cady" on pM ttpty tesla pe'loss jp apo Mwo perday.perv�letlon or adminis- <br /> tredve ponalfies to$5,t per 6 r day dbed in.Public Resourm Cod sootiest 42952. ( i <br /> Vhv s Name(Print):. Ilriv r'a Si <br /> 1�5A: 4ttier iizformation(Golden By-Products ur-house use:t�nlly)- <br /> LOCr# L I WEIGHT CERT#: NET WT: <br /> [)Far the other half of this transacdoin,hauler.is also the: ❑Gene or GEnd use-facility <br /> MAN1F'EST'#:M - _B <br /> Znoiden's odwhalf oirwo aetion if :] t of EDT Heulor EDT'Manifest#. 3FVwManifest#in place of 4oldew EDT Manifest�f'for: (cirere oris) Pick-up Delivery <br /> bbrIfidentialhy Claim(applicable to all parties fisted on above):The information provided in Part.1,Part 11 and Part Ill of this form should be consideredconfldentiai,.propttetary,and/or trade secrfst.In accordance with Tide.14,CCR;Section 17041 st.seq,should any member of the public request disciosure of <br /> this Information,1,request that CNYMB contact-me at the address and telephone niamberabove. <br /> Electronic Reporting to CIWMB:Golden By-Products has been authoriZed by CWMB to participate in the Waste and Used Tire Manifest EDT electronic <br /> reporting program.On behalf of the customer listed on this form,Golden By-Products will eleaftwicallytraf emit to ClWMB all required information from this, <br /> manifest form. <br />