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GOLDEN BY-PRODUCTS dba SC:RAP'TIRE COMPANY <br /> P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#:. 1003314 10/07/2011 &rpt) EDT MANIFEST#: 1003314- 00078419 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT#: DIAFOOD BILL TO:. TERMS: NET30 <br /> DIAMOND FOODS, INC DIAMOND FOODS, INC. <br /> 1050 S. DIAMOND ST. P.O. BOX 1727 <br /> STOCKTON, CA 95205 STOCKTON, CA 95201 <br /> TPID# 1107191701 <br /> PHONE: ' (209)96973136 PHONE: (209)467-6764 P.O.#28129 <br /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. GBBALLICO STATE CA <br /> TRUCK#:. G 2-1 LIC PLATE#: + b '1•F DECAL#: I I ' 0H ` <br /> HAULER EXEMPTION: GOVT LEA EXEMPT COMMON CARRIER F]UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: PU DEL <br /> __J <br /> TYPE COUNT U/M UNIT PRICE . EXTENDED AMOUNT <br /> 45'TRAILER SERVICE-105•CU YDS 1.0000 EA 800.00 800.00 <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 800.00: <br /> ,I c`tfy that under penalty of perjury under the laws of the Slate of California that the information provided above is true and correct. In addition,I am aware that falsification of this information <br /> Jm'aay/res`fu�It in civil penalalti�es'uup to$25,000 per day,per violation or administrative penalties up to$5,000jrper violation per ay as described in(Public Resoouurcess Code section 42962. //1j <br /> Facility Representative's Name(Print) ✓✓ll `Facility„Representative's Signa•t+u•ife Date <br /> CHARGE. 0 PAID CK# E <br /> WEIGHT CERT NET WT 1.00.., TONS <br /> codify 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 thatfalsification of this information <br /> may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration,puisuant to Public Resources Code section'42960 and may result in civil penalties up to <br /> $25,000 per dayaper violation or adr inistrat ve per <br /> up to$5,0001per violation per day as;described in Public Resources Code section 42962. <br /> r v: <br /> �' <br /> Driver's Name(Print) "' i f: '+ Driver's•Signatuie _ Date <br /> Confidentiality Clairn (applicable to all parties.listed on,aliove)� The information provided in Part I,Part II,and Part III of this form should be considered <br /> o°��flatQ�l confidential,proprietary,and/or trade secret.Yn,accordarice with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> 0 of this information,I request that CIWMB contact me at the address and telephone number above. <br /> m N � Electronic Reporting tdIWMB: Golden By-Products has been authorized by GIWMB 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 ffom this manifest form. <br /> Customer <br />