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06/_23/04 11:07 FAX 209 6674850_____ G.B.P. Q001 <br /> WASTE & USED TIRE MAIVIFESURECEIPT <br /> EDT TRIP LUG# I003314-11/L /g- ����- FOT MANII='ES'1 k: 1003313-0 006081 -q <br /> bAA rate DICT[, tz['1x u nwo)Cr 0 <br /> Part I_racihty Wor anon (Actual physical lavation of facility) ! ' <br /> Check one: 1EK UP MOM A GENERATOR J DEL.YVRRY TO AN END USE FACH,ITY <br /> !t applicable: uImpurt Export Imp/Exp Location:11 oe -- ----.--- <br /> / GOLDENATC ACCT#:L 1. JZk4l- <br /> NAME: a . <ey G <br /> TIR <br /> ADDRESS: / E PROGRAM ID: <br /> ADDRESS: -7 (� �. .Gr 4(/,{i <br /> CITY,ST,LIP: �j� SITE SufFix: <br /> PHONE: '�►rJ'(�'�✓! C'4 ' ?voa' q <br /> TRAHER#' PIU DEL _7D <br /> CZY <br /> Pant : Load Infcirma6ct TYPE COUNT RAT 70 DOI ARP0 <br /> CUSED THMS passenger �• 23 _� _ _ �� Intcndod Uso: <br /> 'VWHoLE WASTE TYRES Truck T — <br /> PRODUCT: URETRLAU <br /> BOLE T1)t-COUNT(C) Tractor - YCLE <br /> L,CUBIC XAIlDS(Y) 0�16r � - UEL <br /> 0 WRTCiT-1T ft1 LBS(P) Trailer _ -d DDISPOSAY <br /> !DWt?1GHT IN TONS(T) TOTAL <br /> "ray M.,,,,,yor Po V'ry ru nnryrry under in,Iewu of rho State of catllomia that the Wormeticn provided ebov0 w ave and correct.In addition.I am av to Ihw rolelfioatlan al uta Information may raaum in Wvil <br /> 71iay <br /> up to$25,1000 per day,Der vloWiian or d0lnmre8'ativu puualllae up ro 55,000 Oaf v'01""M Por 0ay u 0 oP hn PuoilL rlr.���ee Oode� open 4308=.tinpr,s aautetve',N.—(P�inr) Fae+Kty RrpveseatativC'e signatufc Datc <br /> Nan 3: Hauler Info•madon _ TRUCK#: 411 STATE: CA <br /> NAME: Golden By-Pmdncts,lire, LIC PLATE#: ���� <br /> ADDRESS: P.O.Box <br /> ADDRESS1 13000 Novvpvrr Road <br /> CITY,ST,Z1P: Ballico,CA 95303 DECAL <br /> PHONE: (209)669-4655 i <br /> -- - JUN12l3CISTEI2FD HATT)Flt <br /> HAULM EXEMPTION. ❑GOVT 0 Ac !LEA EXENT1 OCOMMON CA, R tk DRIVER'S L1C#: <br /> I Vno that wdoi oorw-y of oer$ury unwr ow Iowa of the alto or Cauramia met rrw dWmwron proy'J"..l'a"u sod m..oa.r� e.I +r Ink18.u,+c,r nr rola inbrtZnpendonrat Or derdal of fB/1en'd ain.WSeto Tiro Hautes Aaglatis ion pureuent 14 PUbaC.PAGOU "C06a caCdon a2BB?&Tom reau � plv_. ddw up to 135.000 par day. <br /> rra+i..o per1ae145 D to 00 W r„w1aom per day as w6crbed In f ubi iC RA00uroee COCe lection e2e62. <br /> Drivc'sNORc(Ptint) T Driv igna re <br /> Or 4 <br /> Pact 4. Other nformadurt (0olden By-Pmducts in-house use only) 611-100" <br /> LOG# L— - — — — — — —— Wri—11T c'I?R'i'#: _ NET WT'— - —— TONS <br /> CFof the other half of this transaction,hauler is also the: OGcnerator DEnd use facility <br /> _g <br /> MANIFEST#:M- - - -- ----- ---- - - - --- --- ---- - -- --- - --- <br /> -iGoldan'8 other boli ut rram/enon d D04ter L•DT Heulu WT MuahE5t i JNrper manitcai D is pLvz of Gokkfaa L7r MaaifeU4 fbv: tciftle aw) Plck•ur Tkhvc;v <br /> Confidentiality Clain(applicable to all parties listed on aDove):The information provided in Part 1,Part II and Part 111 of this form should be considered <br /> conficlentiai,proprietary,and/or trade bvuw.til eucorcJance with Tido 14,CCR.Section 17041 eLseq,chni ild any member of the public request diaCloSUre of <br /> this Information,I request that cIWMt3 contact me at the address and telephone number above. <br /> EleWunic RoWling to CIWMB:Golden By-Products has been authodZed by MMB to participate in the Waste and Used Tire Manifest EDT electronic <br /> reporting plttyraii t.Orf Lahalf of tho customer r*tcd on chic form,Goldon Ay-Prodiftis wig mFintronieally,trawmit to ClWttms ail required information from this <br /> manifest form. <br /> 1106:309 <br /> S0 3�hd 331NM4 0b9Z1Gr6_G0Z 0Z':00 b00Z'/C 0 <br />