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FRAM :TRACY MATERIAL RECOVERY FAX NO. :2098323062 �. 23 2008 10:34AM P3 <br /> GOLC EEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br /> P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> Et- . TRIP LOG #' 1003314- 03/07/2008 7- 8 I EDT MANIFEST#: 1003314- 00054623 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT#: 28KZTM BILL TO: TERMS: NETO <br /> TRACY MATERIAL RECOVERY TRACY MATERIAL RECOVERY <br /> 30704 S MACARTHUR P.O. BOX 93 <br /> TRACY, CA 95379 TRACY, CA 95378 <br /> TPID# 1107036-01 <br /> HAULERISHIP VIA: GOLDEN BY-PRODUCTS // 13000 NEWPORT RD. RBALLICO STATE CA <br /> TRUCK W G- 101 LIC PLATE W J606313 313 DECAL aR: <br /> HAULER EXEMPTION: <br /> GOV'T F� LEA EXEMPT F7 COMMON CARRIER Q At. UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: _j <br /> ["5523S7 DEL,53(( �6� <br /> TYPE COUNT U/Mw UNIT PRICE EXTENDED AMOUNT <br /> 45' TRAILER SERVICE-105 CUBIC YARDS 1.0000 EA_ 1 025,00 1,025.00 ry <br /> FUEL SURCHARGE-TRAILER 1.0000 LOAD 40,00 40.00 <br /> TOTAL 1,065.00 <br /> PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE S_ENT_I <br /> I certify that under penalty of perjury under Iho laws of the Slow of California that the information provided above Is true end corr" In addilion.I Aril swam that falslfleation of INS Informetlon <br /> may result in civic ponaltw up to 526,000 per day,per violation or administrative ponalfies up to Sr000 parviolationper day as described in Public Resources Codo section 429(17.. <br /> Facility Repreeentative's Name(Print) Facility Repreaentativa's signature Date <br /> [—]CHARGE ❑ PAID CK# <br /> WEIGHT CERT NET WT 1.00 TONS <br /> 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,1 am aware that faisiflcotion of this Information <br /> may result in suspension,revocation,or denial of renewal of the Waste Tire Mauler Regielration 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 85,000 per violation per day as described in Publi_Rasoumas Code section 4W2. <br /> X 7- <br /> E�j YC <br /> Drlver'a Name(Print) Driver'a Signature Date <br /> Confidentiality Claim (applicable to all parties listed on above): The Information provided in Part I,Part It.and Part fit of this form should be conaldered <br /> Darq r confidential,proprietary,andror trade Secret. In accordance with Title 14,CCR,Section 17041 st.aeq,should any member of the public request disclosure <br /> of this Information,t request that CIWMB contact me at the address and telephone number above. <br /> Electronic Reporting to CIWI►MB: Goiden 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 tinted on this form,Golden 13y-Producia will electronically transmit to CIWMB ail required <br /> information from this manifest form. <br /> Customer ��� <br />