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f - <br /> GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br /> P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br /> BALLICO, CA 3 (209) 668-4866 <br /> EDT TRIP LOG#: 1003314- 08110/2013 ,��- EDT MANIFESTO' 1003314 00088994 <br /> - DATE ,DRIVERS INTT RUN k <br /> SHIP TO: ACCT#: DELSTK BILL TO: TERMS: NET30 <br /> DEL RAY TIRE-STOCKTON DEL RAY TIRE-STOCKTON <br /> 4167 S. B STREET 2544 S.CHERRY STREET <br /> STOCKTON, CA 95208, FRESNO, CA 93708 <br /> TPID# 1750912-01 <br /> PHONE: (209)983-3000 PHONE' (559)485-1761 <br /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RE11- BALLICO STATE CA. <br /> TRUCK#; G ` tr U l !_IC PLATE M /1 �G�(J(,-J� DECAL�: / �/�•2/ J! <br /> HAULER EXEMPTION: 11 <br /> GOVTLEA EXEMPT COMMON CARRIER UNRE6I: <br /> STEREp HAULER <br /> SPECIAL INSTRUCTIONSTRAILER. [ro �; DEL W rj- <br /> TYPE . —���� .J�COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> 45' TRAILER SERVICE-105 CU YDS 1.0000 EA 800.00 800.0n <br /> PLEASE PAY FROM THIS INVOICE NO OTHER INVOICES WILL BE SENTI <br /> Invoices over 30 drays are subject to a late tee of 1 1/21/16 per month, <br /> which Is 18%annually, or a minimum of$1,00 per month. TOTAL 8Q4.0 <br /> i certiry,tne%tvr4er pe-4 or perwy under 149IoW=of the State M Callfomla ttku.lhe irfvmm'.iaj prWdad above Iz;Sue and meet to edd4lon,I am ayes thal faWfIcetion or4118I nfamwrian <br /> may mW1 In O[Vii p■m"ias up tU 62A 000 per daps,P�Qtotatton or edmtrliwative Paro lea tp io Mom per <br /> Y-,loWlem Rs day ea deeMbed Ih Photic Rasourres GOOD eec8on 42962. <br /> --- v--'�- > Date <br /> FaclBty Representatives Name(Print) ; J Pacil(ty Repreeerrwe s Signature <br /> CHARGE PAID CK# <br /> WEIGHT CERT NRT WT 1,00 TONS <br /> i oamry that under penalty 0 perfury unor the Imus of the State of Callfomia dot the inrarm94bn provided ebova is true and rmrrecL in addition,t wn mthat faleMC811Dn of thlc iaforrnafion <br /> may rasLJ i In stupen.ion,revocauon,or dental of ronmoat of the Waste Tire Nsuter Rzgisurtion pureusm to Pub9c Resou=Cade eeuwon 42963 en4 may instil in 60 penelllas up to <br /> s2b,0oo par day per vlolatlat w adminletraUve penalties up to 98,000 per WW atlon per fty as deaeneee to vutnlo Reechoes Cee.■.edon 42842. <br /> X f>L f r l T �„ r Ory}� f X _-�.%` �r� •Q p - 0- /,3 <br /> Driver's Name(Print) Drivel's Signature Date <br /> QvnfidPntiallty Chlm (applirabia to all.pates listed on above): Ve InforrnatlDn provided in Part I,Part 11,and Part III of this Form should be considered <br /> OatQ r confidential,proprietary,andlor trade sennet In accordance with Tille 14,CCR,Seolion 17041 etseq,should any member or the public requestdtsWoaure <br /> L'b ' of lids InformaWn,I request that CIV NB contact ms at Y)e address and telephone numbcr abovc. <br /> Oiectronle li eportina to cIWMIM Gdden BY-Products has been authorized by CNVMD to participate in 9 a Waste and Deed Tire Manifest EOT <br /> ale0rania rvporiing program Qn behalf of the oustomer listed on this form,Golden By-prnduaLs will efettronlawly transmit to cMMB all required <br /> fiformeon from thio manifest form, <br /> r-t t-termer. <br /> Received Time Oct, 8. 2013 3, 02F'V N,3, 0'37 <br /> E0/Z0 39Vd !t,3-19'09 l,.V3_3G ss :ZZ IOZ,'30;'0i <br />