Laserfiche WebLink
JUN-20-2012 13:211 TUFF BOY TRAILERS 2092397086 P.02 <br /> GOLDEN BY-PRODUS6 dba SCRAP TIRE CORWNY <br /> P.O. BOX 1 / 13000 NEWPORT RD. ` <br /> BALLICO, CA 95303 (209) 668-4855 INVOICE <br /> EDT TRIP LOG#: 1003314-.LB/15/2012 RA 1 EDT MANIFEST#: 1003314- 00082373 <br /> ' DATE DRIVERS[NIT RUN# <br /> SHIP TO: ACCT#: PEDRO BILL TO: <br /> P J TIRES TERMS: NETO <br /> 1044 PEDRO'S TIRES <br /> S. ADELBERT AVE 2305 S. AIRPORT WAY <br /> STOCKTON, CA 95215 STOCKTON, CA 95206 <br /> TPID# NEED#-01 <br /> PHONE: (209)271-3934 PHONE; (209)271-3934 <br /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD, BALLICO <br /> TRUCK#: GBP085 STATE CA <br /> LIC PLATE#' CA9655421 DECAL#; 12-04182 <br /> HAULER EXEMPTION: GOVT ❑ LEA EXEMPT COMMON CARRIER UNREGISTERED HAULER <br /> TRAILER: DE <br /> L SPECIAL INSTRUCTIONS: <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE-COUNT EA <br /> Nv <br /> PLEASE PAY FROM THIS INVOICE- NO OTHER=WILLInvoices over 30 days are subject to a late fee owhich is 18/o annually, or a minimum of$1, TOTAL <br /> 1 coriity that under penalty otperjury under the laws of the State of California that the Information provided above is truo and comocl. In addition,I em awarr,that falsification of this information <br /> may result in civil penaffies up to$25,000 per day,per violation or edministrativo penalties up to$5,000 per violation per day as doscrlbed in Public Resources Code secrion 12962, <br /> Facility iZepresentatWe's Name(Print) Facility RepreserrtetlGo's Signature <br /> CHARGE <br /> 'PAID CK# <br /> WEIGHT CERT NET WT TONS <br /> 1 <br /> I certify that under penalty of perjury under the Laws of the&ate of California that the information <br /> may result In au prov{antded above c true and correct, a addition,1 am aware that falsification of this Information <br /> y spar viola revocation,or denial of renewal of the Waste Tire Hauler Re daya s d pursuant to Public feesburras Codo seption 42$60 and may rosult in civil penalties up to <br /> $25,000 per day per violation or adn 1pistralive Penalties up to$5,000 par vlWaiio l pp day as described in Public Reaou�tes tCode seclion 42$62. <br /> DFver's Name(Print) <br /> s <br /> "- Drivers Signature,' - <br /> - Date <br /> Confidentiality Claim (applicable to all parties listed on above): The informali0n provideq in Part I...Part II,and Part III of this form should be considered <br /> confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> v , <br /> of this information,I request that CIWMB contact me at the address and telephone number-9b6ve. <br /> m <br /> ' Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to participate In the Waste and Used The Manifest EDT <br /> electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will eletVonically transmit to CIWMB all required <br /> information from this manifest form. <br /> Received Time Jun. 20. 2012 1 : 13PM No, 0101mer <br />