COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

GOLDEN BY-PRODUA dba S RAP TIRE COMP. Y P.O. BOX 1 113000 NEWPORT RD. INVOICE BALLICO, CA 95303 (209) 668-4855 EDT TRIP LOG#: 1003314- 06/18/2014 JA 1 EDT MANIFEST#: 1003314- 00007465 DATE DRIVERS INIT RUN# SHIP TO: ACCT M BILL TO: TERMS: TRACHEV NET30 TRACY CHEVROLET TRACY CHEVROLET 3400 AUTO PLAZA WAY 3400 AUTO PLAZA WAY TRACY, CA 95304 TRACY, CA 95304 TPID# 1538688-01 PHONE: (209) 835-4500 PHONE: 209) 835-4500 HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA TRUCK#: GBPO85 LIC PLATE#: CA 9B55421 DECAL#: 14-04519 HAULER EXEMPTION: ❑ GOVT LEA EXEMPT F�COMMON CARRIER UNREGISTERED HAULER TRAILER: PU DEL r SPECIAL INSTRUCTIONS: TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT PASSENGER TIRE-COUNT EA 1.25 TRUCK TIRE-COUNT EA 5.50 CAR RIM-COUNT EACH 1.00 PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENIt. _ Invoices over 30 days are subject to a late fee of 1 112% per month, � which is 18% annually, or a minimum of$1.00 per month. 1 1�1�A 16 I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct. In addition,I am aware that falsification of this irNWmation may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to 55,000 per violation per _y as described in rVesources Code section 42962X A Facility Rep s ntaNie(Printf . _ Facl R ase Ive nkure at CHARGE F—] PAID CK# WEIGHT CERT NET WT TONS I certify that under penalty of perjury under the lawn of the Slate of California that the Irdormetlon provided above is true and correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renenval of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to $25,0"r day per violation or administrative penalties up to$5,000 per violation per day as described Vz ources Code section 42962. X r- I , - ' Driver's N me(Print) Driver' Signature Date Confidentiality Claim (applicable to all parties listed on above): The information provided In Part I,Part II,and Part III of this form should be considered er`�Damp T� confidential,proprietary,and/or trade secret in accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information,I request that CIWMB contact me at the address and telephone number above. m w • ` Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT • electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required information from this manifest form. Customer