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TUN-20-2012 13:221 TUFF BUY TRAILERS 2092397026 P.03 <br /> GOLID1 N BY-PRODUCTIIba SCRAP TIRE (;OMF JY <br /> P.O. BOX 1 / 13 00 NEWPORT RD. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314- 06/16/2012 AM 1 EDT MANIFEST#: 1003314- 00082428 <br /> DATE DRIVERS NIT RUN <br /> SHIP TO: ACCT#: PEDRO BILL TO: TERMS: NETO <br /> P 8r J TIRES PEDRO'S TIRES <br /> 1045 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 STATE CA <br /> TRUCK-9;: LIC PLATE#: <br /> GBPO87 CA8W56341 I DECAL#. 12-04194 <br /> HAULER EXEMPTION: GOVT U LEA EXE=MPT COMMON CARRIER UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: E7��� <br /> DEL <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE-COUNT EA 0.80 i <br /> %7 <br /> TRUCK TIRE-COUNT EA 3.00 <br /> `� / <br /> PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL BE SENT! <br /> Invoices over 30 days are subject to a late fee of 1 1/2% per month, ._: -• ;, ,� <br /> which is 18% annually, or a minimum of$1.00 per month. TOTAL <br /> I certify tnal under penalty of perjury under the laws of IN Stara of Callfomla that tho information provided above Is true and correct. In add,ticn,I arp aware trial falsification cf this information <br /> may result in civil penalties up to 52',000 per day,per violation or edmini&trative penalties up to s5,000 per violation per day as deecrSbedl(n Pbli espurcaa Code rection 42982. <br /> X 411 / h/ . ; yr )( � .:. <br /> Facility Representative's Name(Print) fJ Facility ReprCsrnfaUve'a Signature .' Date <br /> CHARGE © PAID CK# f"5 �T <br /> WEIGHT CERT NET WT TONS <br /> I certify that under penalty of penury under the Taws of the State of California that the information provided above Is true�and corrSCl, I additial,I am awaro Ih.t fals`\ation of this informatics <br /> may result In suspension,revocation,or denial of renewal or the Waste Tire Hauler Registration pursuant to Public Re6ourc�§' ode' edioit 42960 and may resul 60 penalties up to <br /> $25,000 per day per violation tx ecminlsuativo penalties up to S5,000 per violation per day as dercribod in Public Re9ource4Coda4ectir 42962. <br /> Driver's Name(Print) Drlver'e Signature Date <br /> Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part It,and Part III of this form should be considered <br /> caro+ 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 /> y o� of this information,I request that CIWMB contact me at the address and telephone number above. <br /> m Electronic Reporting to CIWMB- Golden By-Products has been authorized by CIWMB to participate in the Waste and UsM Tire Manifest EDT <br /> • electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required <br /> information from this manifest form. <br /> cel d Time Jun. 20, 2012 1 : 3PM No 0101�mer <br /> TOTAL P.03 <br />