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GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br /> P.O. BOX 1 113000 WWPORT RD. INVOICE <br /> BALLICO, CA 96303 (209) 668-4856 <br /> EDT TRIP LOG#: 1003314- 08/29/2013 � EDT MANIFW k 1003314- 00081007 <br /> DATE DRfVERSINIT RVN# <br /> SHIP TO: ACCT DELSTK BILL TO: . TERMS: NL-F30 <br /> DEL RAY TIRE-STOCKTON DEI,RAY TIRE- STOCKTON <br /> 4167 S. 5 STREET 2544 S.FRESNO,CHERRY <br /> REST <br /> STOCKTON, CA 06206 <br /> TPID# 1750512-01 <br /> PONE: (209)983-3000 PHONE: (559 485-1761 <br /> HAULERISHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD- �7 I DALLICO STATE CA <br /> TRUCK#: LIC PLATT=#: , �+'S r^ DECAL* <br /> HAULER EXEMPTION: GOVT IJ LEA EXEMPT F] COMMON GFtRRIER UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: DEL <br /> " -Z S LI <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> 45'TRAILER SERVICE-105 CU YDS 1,0000 EA 800.00 800.00 <br /> Iv— <br /> PLEASF=PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENTI <br /> Invoices over 30 days'are subject to a.late fee of 1 112%per month, <br /> which is 18%annually, or a minimum of`81,00 per month, TOTAL 800.00 <br /> I oerlrty,hat under penalty of penury under the laws of the Orate or Catiromta that the kiform4pe praudad above Is true and wmeet In aCdNoq I am Mare dialfals GGMIon oithla Ir format on <br /> mgy reault to olvll penettl¢s up to=,0D0 Pat Gay,Par Nolauort or achnlniWaDve penaBb:up m 66,0Do per violation pet gay as dasaribid in PUD110 ROCOMW Cads 46000 42962, <br /> Pact[ffy R Uire's Nems t),.� Faolbty,ItppredEt>EaU+re'n slgnadilrA pQ� <br /> CHARGE F-] PAID CK# <br /> WEIGHT CERT NET WT 1.00 TONS <br /> I pantry that under penalty of perjury underthe lava or the 8tate of C:.R rua that"vomlation provided above is MA and exrom In addition,I em aware lhai fa slfcsarl of ltrle lnfomratfon <br /> may,result rn�uzpen:Pn,reyooeu6n,or danial of rerawal m the waste lire vAuier p6oistravon pursuant to Pubtlt Raaourua code sedbn 42960 and may realm in ow panalii—up to <br /> ,qoo pqr lay par vloladon Dt adlttnlatmilva ponaluaa up to mono por vlotntlon par day Pa guotzw in ru uo Rs w-"Goch sortion <br /> X ^�`�. •—tib � �,�~---�� f'� <br /> Driver's Name(PrIM) Drive a re Dafe <br /> ConfldenUallty Claim (eppllcabla to etll patlira liattd on abovO): The Infom1a60n provided In Part I,Pert il,and Part III of mla form should to oorlaidered <br /> e A e� nl3dantla4 aoproPric+�ry,and/Gn 0ade seaet, In sccordanes vitt Tltie 14,CCR,Section 17041 et.sea,should any member of tits public requQ%&dasute <br /> ' of iitl8 infyrmstbn,l request that CIWMB contact me at the address and w epnone number above. <br /> Eleationlo Re parting to CIWMB: Golden 6yPrvducts has been authorized by CNvMB to participate in the wasta and Used Tire Manifest EDT <br /> ekwbonio repodrQ proGram• On bahalt of the customer listed on d)1s four,Golden By-Products will electronically trattsrnh to CI ME all regWred <br /> tnforrnadon from this manifest form. <br /> r`r to+„mer <br /> Received Time Oct, 8. 2013 3: 02PM No. 0837 <br /> L"0fE0 39Vd h3-19VEI /,t1�t13G VELZLEZS99 99:ZZ ETOZ/80/Ol <br />