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FROM :TRACY MATERIAL RECOVERY FAX NO. :2098323062 23 2008 10:34AM P4 <br /> VV�.V ill 0 1 -rRVIJVL 1 a �VRflr'. 1 IRcG vV1Y1�" <br /> • P.O. �OX'1 / 13000 , , .. .,, - <br /> . <br /> f : NEWPORT <br /> BALLICO CA: -96303 (209)'Q,08-4855 <br /> IL <br /> t TRIP LOG* 1003314— 11/28/2007 <br /> � EDT MANIFEST#: 1003314— 000$28$6 <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 /> HAULER/SHIP VIA; GOLDEN BY—PRODUCTS 13000 NEWPORT RD. BALLICO STATE= CA <br /> TRUCK* G/t"l LIC PLATE#: ">�YL�1 ','�. DECAL#; <br /> HAULER EXEMPTION: <br /> 11 GOVT F] LEA EXEMPT [] COMMON CARRIER ❑AG UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: -7 DEL _ <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> 45'TRAILER SERVICE-10_5 CUBIC YARDS 1.0000 EA 1,025.00 1,025.00 <br /> FUEL SURCHARGE—TRAILER Y _ 1.0000 LOAD 40.00 40,00 <br /> TOTAL 1,065.00 <br /> PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL BE S_ENTI <br /> I oanify theft undor ponnliy of perjury under the laws of the Slate of California that thoyinformation provided above Es true and correct. In addition,I am aware that fslsitrantlon of this infurrnution <br /> may result In civil peneltlea up to$25.000 per day,per violation or adminletraWe peneltfes up to$5,000 per violation per day sa deecribetl in Public Reaotimas Codo sootion 42962, <br /> Facility Representative's Name(Print) f=acility Rapresantative'o Signature Date <br /> 0-CHARGE PAID CK#_ <br /> WEIGHT CERT NET WT 1.00 TONS <br /> I certify that undor pranalty of perjury under the laws of the State of California that the information provided above Is true and eoerett in addition,I am aware that falsification of this information <br /> may result in auepeneion,ravoaatlon,or danlsl of ronowal M the Waste Tire Hauler Regisirailon pureuani to Public Resources Code section 620430 and may result In civil ponolilas up to <br /> $25,0'o per day per violation or admiristmove penalties up to$5,000 per violation per day as described inPublicResources Code section 42962. . <br /> Driver's Name(Print) Driver's Signature Date <br /> Confidentiality Claim (applicable to all parties listed on above); The information provldod In Part I,Part II,and Part III of this form should be considered <br /> "c Dttrgr Confidential,proprietary,and/or trade secret, In aceordance with Title 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 CIWMB; Golden By-Products has been authorized by CIWMB to participate In the Waste and Used Tiro Manlfest 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 /> ..... n�.... ...._...,.._...Customer ,�.,._�._..._.�.._......�.. ..._-.,.._.... <br />