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GOLDEN BY-PRODUCTS WASTE & USED TIRE MANIFEST/ItECEIPT <br /> _ _ ' <br /> EDT TRIP LOG#: 100331 - /� b Lt -} - � EDT MAN1) E5�1'I�: lUU331� O <br /> -R <br /> DATE DRV INTL RUN i. INVOICE 4 <br /> Part 1: Facility Information (Actual physical location of facility) <br /> Check onc: 'PICK UP FROM A GENERATOR I i DELIVERY TO AN END USE FACILITY <br /> If applicable: 1111poit ~Export Impi(Exp Location: _ <br /> - --- -- GOLDEN/STC Ac:c-ru <br /> NAML:: A%vb0's0W - - -- - - - - <br /> ADDRESS: TIRE PROGRAM ID: <br /> ADDRESS: '!cI i:, �1� �s �� Five. — — — — — — — <br /> CITY, ST,ZIP: S" or- SITE SUFFIX: 0 7< <br /> PROM': <br /> TRAILER#: P.U DEL <br /> Part?: Load Information TYPE COUNT RATE DOLLARS <br /> J USED TIRES er PASSER r-A Ck 13 --15 - i <br /> ^11-10LE WASTE,TIRES g Intended Use: <br /> Truck <br /> I PRODUCT: -Tractor I:IRETREAD <br /> � _ �ZECYCLfi <br /> ^-IOLt~TIRE COUNT(C) Other _ @ _ ,~-(FUEL <br /> I- YARDS(Y) Trailer @ = I:iDISPOSAL <br /> L�WEIG6IGHT 1N LBS(P) 3 <br /> I iWLIGHT IN TONS(T) TOTAL I u CA <br /> I COTry Inplunderpenny Or poqury unow we lawn yr tow 31aw vi Car r„�,.ia aur Ilw 6•Mnierwn P'C'IdGd obarc 4nd 4o.'rool.In addn— f of r-111 in 11.11 <br /> pa'&L'ee up 10$2 .000 per day,per vlaatlon or odm-i�waL-o penanles un to:65.000 per vioiatKnr per deg es ocscriD"d in Publlc Resources Codo-caion 42862. <br /> J A S 0 <br /> Fac'iiiiy Rcprcienwti c s Nam;(Print) Ya Lily Kcprt>uluu c'a 3iguuluro I+tC — <br /> fart 1: ilaulor Information <br /> - - TRUCK.f6: STATE: CR <br /> NAME: Golden By-Prod"I.6.Inc. t 5 <br /> A I)Ok F.SC: P-0.Box 1 It-oat` LIC PLATT ft: - <br /> ADDRESS: 13000 Newport Road <br /> CITE".ST,ZIP: Bullicu,CA 953U3 DECAL,#: �- ® V �{ — 00 4 lot ot <br /> prrnva (2119)668-4855 - <br /> 1=:UNREGISTERED HAULER <br /> 11RULLREXEMPTION-. '�covr Ac _!LEA EXEMP1- 1.'COMMONCARRIL12 i DRIVER'S LIC 4: <br /> t tanlry 11191 under perahy of penury w,06f lnE 16WG of ilio st'ite ni Cn6'folni9 Ina1419 Intormatvi prOviced above it;e'ua find COrrW In addliolt.I;i111 Bware Thal fal3lfication or lhi'infurrnallOn may re5'uk in Sus- <br /> Damsion,rcvocatian,Or dioial Of reneWal of tho Ltlyyr.rira Hauler Registration pur54:Inl In PvUk R68ourcea Code Wion 4.9110 and Inlay rasull In cin~ponaitit�up W 625.000 Va day.per violawn Or ildnld'•�r <br /> 1—".p4--up ro OnO rte• p.:nry as ct—r bort,n Public Rauourorr code section a29G2. <br /> �► ~� 5;,.1`-1�I t.� . _ 6 ± dS.J.,..�.� �,l �,�.ti3scoc'e 'I� �. _6 1�� �t-R <br /> llnver's\umo(Print) Drrvdr's Sienaturo Da u <br /> 'arl 4: other Information(Golden 13 -Produce in-house uic only) <br /> LOG-4: L - WEIGHT CE-RT#: — — —— _ , N ET WT:— — — 'rUN S <br /> ,For the other half of this transaction,hauler is also the: !Generator -.~End use lacility <br /> iMANIFF_S`I'#- M- - - -- -. - - - - - - -- - --- - - - - - - - - - - -- -- -- - - - - - - 13 <br /> Guldcn's otlx r fwdrl„lritu3cl JU w Other 171)I'I1-1,;r EDT M;uiifcat It %".r hla[i1rJ:l 4 Ill plav':OI C-014)eru kA f Manllcil a for: (tiri li CDC) 1'icL.up DLhV Yv <br /> k�AarQ Confidentiality Claim(applicable to 811 parties lig ea on above):The inrornlatlon provided in Part 1.Part 11 and Part III of thle form Should be considered conii- <br /> voo PrP dontiai.proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 e1.seg.Shovid any Mom or IN;publlC reQuest disclosure of this <br /> Information.I request Dial CIWME contact me at the add- a o1Od 161aphons number above. <br /> d <br /> w m <br /> Electronic Reporting to CMtMB:Goldtin ey-f'rOduCKs has been au4toii_cd Dy CIWMB to participa!a 111[he Waste and Used Tire Munikst CDT electronic <br /> reporting prograrn.On behalf or the custorner listed on this form,Golden By-ProdUCIS will electronically lranz mil to CIWMS all required infonmrlion from this <br /> manrtest 10MI. <br /> CO 39Vd 331[4VV4 0r9(Gt?160z 0z:00 tr0071/6-6/90 <br />