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GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY R.O. BOX 1 / 13000 NEWPORT'RD. INVOICE BALLICO, CA 95303 (209) 6618-4855- EDT 68-4855EDT TRIP LOG#: 1003314-:10/07/2011 'D EDT MANIFEST#: 1003314- 00078417 DATE DRIVERS INIT ,RUN# SHIP TO: ACCT#: DiAFOOD BILL TO: TERMS: NET30 DIAMOND FOODS, INC DIAMOND FOODS, INC. 1050 S. DIAMOND ST. P.O. BOX 1727 STOCKTON, CA 95205 STOCKTON, CA 95201 TPID# 1107191-01 PHONE: (209) 969-3136 PHONE: (209)467-6764 P.O.#28129 HAULERISHIP VIA: GOLDEN BY-PRODUCTS 1 13000 NEWPORT RD. r BALLICO STATE CA TRUCK#: G LIC PLATE#: l' Lr f II DECAL#: (r. HAULER EXEMPTION: GOVT F—] LEA EXEMPT F-1 COMMON CARRIER UNREGISTERED HAULER SPECIAL INSTRUCTIONS: TRAILER: PU DEL 47 7 TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT 45'TRAILER SERVICE-105 CU YDS 1.0000 EA 800.00 800.00 PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL BE SENT! Invoices over 30 days are subject to a late fee of 1 1/2% per month, which is 18%annually, or a minimum of$1.00 per month. TOTAL 800.00 I certify that under penalty of perjury under the laws of the State of California that the informationprovided above is true and correct. In addition,I am aware that falsification of this information may result in civil penalties up to$25,000 perday,per violation or administrative penalties up to$5,000 per violation per day.as described in Public Resources Code section 42962. Facility Representative's Name(Print) ' Facility Representative's Signature 1_ Date v CHARGE PAID CK# WEIGHT CERT NET WT 1.00 TONS t 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 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 $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. XI if;t,) �_',v f ;fir., X .�`-'f:r'.. •�.. -�_f,:,, �L`' I 'I�� Driver's Name(Print) �/ Driver's 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 °Daro r 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. W I. f•11m 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