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A-7 <br /> Pg, j,DEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br /> P.O. BOX f/ 13000 NEWPORT RD. <br /> INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314 07/09/2013 /' „ _ EDT MANIFEST# 1003314- 00089679 <br /> DATE DRIVERel INrr .RUN# <br /> SHIP TO: ACCT#: DELSTK BILL TO: TERMS= NET30 <br /> DEL RAY TIRE-STOCKTON DEL RAY TIRE-STOCKTON <br /> 4157 S. B STREET 2544 S. CHERRY STREET <br /> STOCKTON. CA 95206 FRESNO, CA 93705 <br /> TPID# 1760612-01 <br /> PHONE: (209)983-3000 PHONE: 559 466=1761 <br /> HAULERISHIP VIA; GOLDEN BY-PRODUCTS 13000 NEWPORT RD, BALLICO STATE CA <br /> TRUCK#, G i, UC PLATE 4: r�T � ", �/ DaCAL 41� '-r ? r j !! <br /> HAULER EXEMPTION: COV'TLI'A PacEMPT COMMON CARRICR UNRR0113TERED HAULER ; <br /> ttw' <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER; PU DEL <br /> TYPE COUNT U!M KNIT PRICE EXTENDED AMOUNT <br /> 45'TRAILER SERVICE-105 CU YD5 1.0000 EA 800.00 800.00 <br /> PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENTI <br /> Invoices over 30 days are subject to a labs fea of 1 1/2% par month, <br /> which is 181/16 annually, or m minimum of$1.00 per month. TOTAL 800.00 <br /> I cetlMy!Ret under penalty of pgrjury tnderthe laws of the Stere of CafJomia that the irrfom+aiian prDviddd above is.aue and r>are'3 In ad%irwmt I sm*w*.0Ut nm Hirattan of INInfmmarkn <br /> may resat In oNa pen-pros Lo tp 825,00d p&r ddy,per Valatlon or edminlstretive pgnahles up to 56.000 per violation ver d n dnci bM in PUtdie R ourcos Ccde,sodion 429112, <br /> X !` <br /> �I,1-` I 1 `.y .-,�w �d ,v� ` �"" � f� tri�' '" r•� ��.i.•���„z'- <br /> Pacility Repres nWive'S Mame(Print) Fecillty Representative'e 51 p MUrir' DMto <br /> [CHARGE PAID CK# <br /> WEIGHT CERT NET WT 1.00 TONS <br /> I=*041 under pe 0y of perjury LUtdw the lewa of the stere of Ce4fornla Diet Vie U+formetlon provided above Is true and correct In add tion,I am aweuv that faisific�ien of chis iTfem r m <br /> may rowlt in sirpdnsion,feweaHrm,or denial of renewal tat rho Waste Tra Mauler Raelalragion pUMLIant ro Poll*nas>rrroaf Coda overran 422ee0 RN may result in civil panalilge up to <br /> 0 Pw daY P-vialvt/on,ot sdrrtin� N.P. 1as up 10 66,000 pr p6e dq ua dddoib d to PUbli"65OW00o COCO 0001-On 49'a . <br /> Driver's Name(Print) of leer's Sigj(ature cote <br /> Confidentiality Claim (applicable to all partes ftated on above): The information provided in Part I,Part u,and Part III of this form should be cortsldered <br /> oarifidenNal,proprietary,dndro f Itsda treorat. In aocordancm with Tina 14.MR,13 e M 17041 etaeq,apould any member of the public request dimlosure <br /> of wa iafarnia6w,t wquast that CIWMB aori et m('t at me aclaws end telephone nvmbar eboue. <br /> Electronic Reporting to CIWMB: Gn f wl By-Products has been authorized by CIW1dB to pwdc)pate In the Waste and Used Tire Manifest EDT <br /> dadfonlo reportlag program. On banalf of the memmer tiered on tale form,Oolden By.Producm 0111 ejectrpnioaily tmnamtt to CIWMB all required <br /> Information from this manlfeet form, <br /> ri IQt(1-mer <br /> Received Tlme Oct, 8. 2013 3. 02RM k 083 / <br /> CO/ze 39cd "13-101J2 ,11cd_13a VE Zz Ez6ss GG:ZT ETez/8919T <br />