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t + C:DN�EY-Pt4UC dba P COMA Y <br /> P;6sox I I X300© ice: I IVVCyhC <br /> BALLICOi CA 95303 0 �. s s <br /> EDT TRIP LOG# 10193314, 11_/06/2013. Mme! .�1 EDT:MANIf=EST#. 1003314 00092413 <br /> qAl E DRNER$INfT. ,RUN,# :.. <br /> SHIP TO: ACCT M. TRACHEV BILL TO TERMS: NET30 <br /> `TRACY CHEVROLET. TRACY CHEVROLET <br /> 3400 AUTO PLAZA WAY '340Q.AUTO PLAZA WAY <br /> TRACY,CA 95304 TRACY,CA 95304 <br /> TPID# 1638688-01 . <br /> PHONE: (209)835-4500 PHONE: 209 835=4500 <br /> HAULEWSHIP VIA: GOLDEN BY PRODUCTS 13000 NEWPORT RD. - BALLICO STATE CA <br /> TRUCK IV . GBP081 LIC PLATE V.. . CA X137.1756 DECAL 0: 13-01094 <br /> HAULER EXEMPTION: GOVT ' LEA EXEMPT E]COMMON CARRIER a UNREGISTERED HAULER <br /> TRAILER: U DEL <br /> SPECIAL INSTRUCTIONS: <br /> TYPE COUNT. U/M UNIT PRICE EXTENDEDMOUNT <br /> PASSENGER TIRE-COUNT EA 1.00 <br /> TRUCK TIRE-COUNT EA 5.50 <br /> CAR RIM-COUNT . EACH 1.00 <br /> PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES VALL BE SENTI <br /> Invoices over 30 days are subject to a late fee of 11/2%per month, <br /> which is 18%annually,or a minimum of$1.:00 per month. TOTAL <br /> I cerriy eut under penalty of penury under the Laws of the Staft of California dw the information provide iabov@ is trite and oofrect. In addition,I am aware that felal m-.ation of this Informeticn <br /> er <br /> may result in civil penalties up to 125,000 par day,pviolation or edrrdnistrative penalties up to$5,000 par vlolatior).p@r*as described in Public Resources Code sedlon 42962. <br /> 1 <br /> 1 <br /> Facility Representative's Name(Print) Facility Representative's Signature Date <br /> CHARGE ❑ PAID CK# <br /> i <br /> WEIGHT CERT NET WT TONS <br /> I owary that under p@rWly of parlay under the laws of the state or Calrfomin that the Irdomtation provided above Is true and sorted. In addition,I am aware that falar6cstion of this information <br /> may result m suspension,revocation,or denial of renewal of the Waste Tire Hader Rlg s"Alon purwent to Public Resources Cod@ section ltd may result in civil penalties up to <br /> $25,000 Peg per violation or adrrriro rve penaldes up to$5,000 par violation par day as described In Public R rtes section <br /> Drivers Name(Print) OldvePa sl Date <br /> Confidentiality Claim (applicable to all parties Iisteci on above): The Information provided in Pan I,Part ll,and Part III of this form should be considered <br /> Dano A oonfidenfiW,proprietary,andlor trade secret In accordanoo with Ttde 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> $ ' of this Information,I request that CIWMB contact me at the address and telephone number above. <br /> Electronic Reporting to CIVI1111M Golden By-Product$halo been authorized by CMNB to participate in the Waste and Used 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 /> Customer <br />