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06/23/04 11:08 FAX 209 6674854C.B.P_ 1002 <br /> WASTE & USED TIRE MANUESUfRECEIPT <br /> IST TRIP LOU#: 1003314-$/ IOa- - _ EDT MANIFEST#: 1003314-0 001897 -A <br /> DATE DRV L I L RUN Is INVOICE8 <br /> Pari : F <br /> 1acility Xnformation (Actual physical location of facility) T l� / // <br /> - t?-// <br /> C'hmk one: :e PICK VP PROM A GENERATOR is DELIVERY TO AN END USE FACIIJTY p <br /> If applicable: DImport CJExport Imp/Exp Location: <br /> ,,IIC � <br /> GOLDEWSTC ACCT#:573�_VJI <br /> � <br /> ,NAMh: VAIM HRRfEy. UP.��dtoK — — ._ OM <br /> ADDRESS. / <br /> ADDRESS: 111 1L fr1 ie.10R. /,N1G r TIRE, P12pGR�.M1A In: — — — <br /> CrN.ST.ZIP: S-'o,VC'co..l CA- SITE SUrPIX_ <br /> PHONE: <br /> TRAILER#: PIU DEI. <br /> Pan 2: Load Inform%aon TYPE COUNT RATE DOLLARS <br /> ❑VSFD TmEs Passenger ® Intended Use- <br /> ;d WHOLE WASTE TIRES Truck 0 - <br /> � '^ ORk3TREAD <br /> uPRODUCT: <br /> Tractor - AZECYCLrE <br /> tawHUL)✓'1"IkE COUNT(C) Other �'�_@ 5 = 1_1. ;AUEL <br /> UCLMIC YARDS(Y) Trailer = ❑DISPOSAL <br /> U WEIGHT LBS(P) TOTAL 14 5 Z�- <br /> uW'EIQHT W II�TUNS(T) <br /> l'-Art tw www ppMiMy or pptllily UntlOr Ta iau'a d 1W$mild at raww ie hm tr*irim motion proyided abovo Irt inn and carma.In ada'W",I&nI 0t are Oat teIBNJ ut tws M.—tion may nwll to r]vY <br /> canal cry to 325 OW par day,oat y1Qa[an tX 0ananla[.wt••.pwirtaua�y W 36.000 Oa violation par dwy m dowlla d In ie F aao•n .,A. <br /> V.rF.iliry Represartatiyc's Name(Print) Faci ity Repwaliteuvc's SiBnatote ere <br /> Pa>Z 3:-Hauler Information TRUCK#: — —�Z SPATE. CA <br /> NAME': Gulden By-Produclb,Inc. <br /> ADDRESS: P.U.Box 1 LIC ATE#= C Q Z S <br /> AODRESS: 13000 Newport Road <br /> CITY,ST,ZIP: BJfllico,CA 95303 DECAL#: <br /> PHONE: (?(0)669-4855 <br /> IUNREGISTER.ED HAULER <br /> HAULEREXENIPTION: DGOVT ❑ AG OLPAEXE-MV1 ❑COMMON CARRWIR DRIVER'S LIC <br /> t'Antty Nal armor penalty or taarlwy u.advr u.a m..a.,r the ormc of adu,,,.,Ja tne,rtia Mlo_."n Prevtdod nbc•w..t,.true and rarreuIArt eddlion.I am**ate that towsoation or tris(ntpm auan may to"In aur <br /> pnmaton,rwaaaQOn,of ow"I of ronwaat or are Weale The Hudor Raryatrrd(on pursuant to Pu611c Rroourooa Coda eeerlon 42!)w and may roadt In dya parmltlao up to$26,000 par aoy.par vtataaon or aorrnnto- <br /> ,rawo patowea tm 10 65,Ooo For voIadon per day as acoarload in PUDIk Rasouraeo Code eecarn 4296:. <br /> (rn��♦ 1,r �+ <br /> Driver's Name(print) Driver s Jlgtiacurc <br /> Part 4: Other lnforrna[inn LGolde3►k3y-I'roducu in-Aoupe uFe ontV) <br /> T.O,#:),— - — — — — — — WEIGHT CERT 4V NET WT: _ TOWS <br /> ❑For the other half of rf>ie transaction,hauler is also the: uGenerator L,End use facility <br /> IviANJFEST#:M_,_ ' B <br /> --- ---� — �- - - - - - - - --- -- <br /> ]Calder`s other half vi Innaactior N 7oUror Lar Hau(ec EDT lgattlrcst" ]Payer tulnnifest n in l8ncc.of Gotdene E07 Mnmfest N for. (circia one) Piclt.up lklivery <br /> ConrtaentteMy Clalm(applicable to alt parties listed on above):The Information provided in Part I,Part ii and Part lit of this form Should be oonsldorad <br /> confidontSal,proprietary,6ANor trade secrOl to arena aw.A with Title 14.CCR.Section t 7o41 et.seq,should any member of the public requast digoWsure of <br /> this information,I regtrest that CIWMB contact me at the address and telephone number aDOve_ <br /> Electronic Reporting to CIWMB:Golden By-Product's has been authorized by CIWMB to petNcipate in trio Waste and Used Tire Manliest EDT electronic <br /> reporting pmgrarrl.(1n hah»It of IM Customer listed on thl6 form,Golden By-products will alectrorticaily transmit to clwMB all required information from this <br /> manifW form. <br /> 1,11162.10 Gh�c.tL -' tuAt� AccovaT <br /> VO 3E)hd 331l-MW 0V9Z'6VZ60Z 0(=00 b00z/671/90 <br />