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GOLDEN BY-PRODUC . dba SCRAP TIRE COMP .Y <br /> P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314- 05/23/2014 JR 1 EDT MANIFEST#: 1003314- 00096686 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT*: TRACHEV BILL TO: TERMS: NET30 <br /> TRACY CHEVROLET TRACY CHEVROLET <br /> 3400 AUTO PLAZA WAY 3400 AUTO PLAZA WAY <br /> TRACY, CA 95304 TRACY, CA 95304 <br /> TPID# 1538688-01 <br /> PHONE: (209) 835-4500 PHONE: 209) 835-4500 <br /> EK <br /> ER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA <br /> # GBPO87 LIC PLATE#: CA 8W56341 DECAL#: 14-04528 <br /> HAULER EXEMPTION: 1-1 GOVT F-] LEA EXEMPT n COMMON CARRIER UNREGISTERED HAULER <br /> TRAILER: <br /> PU DEL SPECIAL INSTRUCTIONS: <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE-COUNT EA 1.25 <br /> TRUCKTIRE-COUNT J:% EA 5.50 <br /> CAR RIM-COUNT EACH 1.00 <br /> t <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 /> 1 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 information <br /> may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> _X <br /> Facility Representat Name rint) Facill e a 's Signature Date <br /> 7�,❑CHARGE PAID CK# <br /> WEIGHT CERT NET WT TONS <br /> I certify that under penally 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 information <br /> may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to <br /> $25,000 per day per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code seclion 42962. <br /> ^i 1 <br /> Driv is Name(Print) <br /> i <br /> Confidentiality Claim (applicable to all parties listed on above): The information pro'Vided in Part I,Part ll,and Part III of this form should be considered <br /> o�C Datarr confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 etseq.should any member of the public request disclosure <br /> o� of this information,I request that CIWMB contact me at the address and telephone number above. <br /> _m <br /> Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB 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 />