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FROM :TRACY MATERIAL RECOVER`( FAX NO. :2098323062 1. 23 2008 10:33AM P2 GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY ;s • " P.O. BOX 1 / 13000 NEWPORT RD. INVOICE BALLICO, CA 95303 (209) 668-4855 cL)T TRIP LOG#: 1003314- 04/03/2008 _,,n-," Z. EDT MANIFEST*: 1003314- 00055225 DATE DRIVERS IMT RUN# SHIP TO: ACCT#: 28KZTM BILL TO: TERMS: NETO TRACY MATERIAL RECOVERY TRACY MATERIAL RECOVERY 30704 S MACARTHUR P.O. BOX 93 TRACY, CA 95379 TRACY, CA 95378 TPID# 1107038-01 HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE TRUCK#: G LIC PLATE 0: DECAL#. rr, HAULER EXEMPTION: F1 GOVT F] LEA EXEMPT COMMON CARRIER ❑AO UNREGISTERED HAULER SPECIAL INSTRUCTIONS: TRAILER:, PU DEL TYPE COUNT �U/M I UNIT PRICE EXTENDED AMOUNT 45' TRAILER SERVICE-105 CUBIC YARDS 1.0000 EA - 1,025.00 1,025.00 FUEL SURCHARGE-TRAILER 1,0000 LOAD 40.00 40,00 IM TOTAL 1,065.00 PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENTI I certify that under penalty of perjury under the laws of the State of California that the information provided above is I ue and correct, in additlon,I em aware that falsification of this Information _ may result In civil ponaitie�yip to ts25,00o per day,per violation or administrative penalties up to$5,000 per violation per day as described In Public Resources Code section 42962. KaCII4 Representative's Name(Print) Facility Ropr6sentativRs.Sl6h yre-� I Date CHARGE PAID CK# WEIGHT CERT NET WT 1.00 TONS I conify that under penally of perjury under the laws of the St9te of California that the Information provided above is true and correct In addition,I em aware that falsification of this Information may result In susponelon,revocation,or denial of renewal of the Waste Tire Halder Registration pursuant to Public,Resources Code section 429eo and may result in civil ponalties up to 925,000 per day per fviolation /or administrative penalties up to$5,000 per violation per day as described in public Resources Coda section 42962, s Driver's Name(Print) driver's Sljf4atilirs' Date Confldentlality Claim (applicable to all parties tested on above): The information provided In Part t,Part II,and Part III of this form should be Considered O Dalai , Confidential,proprietary,and/or trade secret. In accordance with TIHe 14,CCR,Section 17041 et.seq,should any member of the pubdr;request disclosure of thls information,I request that CIWMD contact me at the address and telephone numbor above, Electronic Reporting to CIWMB: Golden By-Products has been authorized by COMB to participate In the Waste and Ueed Tire Manifest EDT electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will electronically transmit to COMB all required Information from this manifest form. Customer