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,ADEN BY PRODU ; WASTE & USED TIR TANIFESURECEIPT :DT TRIP LOG#: 1003314- U'`/G/u - EDT MANIFEST#: 1003314-0 U 2 0 6 3 4 -A DATE DRV INTL RUN# INVOICE# Part 1: Facili1y Inform ion (Actual physical location of facility) �UV& Check one: PICK UP FROM A GENERATOR 11 DELIVERY TO AN END USE FACILITY If applicable: ❑ mport ❑Export Imp/Exp Location: GOLDEN/STC ACCT#: � --�Z, �_ _ NAME: Golden By-Products,Inc. `_ ADDRESS: P.O. Box 1 ca Y\ bL TIRE PROGRAM ID: 1003314 ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 �"�� / SITE SUFFIX: O1 PHONE: (209)668-4855 TRAILER#: P/U DEL Part 2: Load Information TYPE COUNT RATE DOLLARS SED TIRES Passenger @ = No Intended Use: L JHOLE WASTE TIRES Truck _@�__ ❑RETREAD �PRODUCT: Tractor Pr @ ❑RECYCLE HOLE TIRE COUNT(C) _ LI CUBIC YARDS(Y) Other @ - _ ❑FUEL LJWEIGHT IN LBS(P) Trailer @ ❑DISPOSAL L WEIGHT IN TONS(T) TOTAL e_ Air I certify that under penalty o(ay, rjury J deL of the State of California that the information provided above is true and correct.I additio ,I a a falsification of this information may result in civil penalties up to$25,000 per per laministrative penalties up to$5,000 per violation per day as described in Public Re ources d s coon 42962. / Facility Representative' Na e rint) Facility Representat a Date Part 3: Hauler Information TRUCK#: _ _ _ _ STATE: ADDRESS: LIC PLATE#: ADDRESS: ZIP: l.' f /� �o VS DECAL#: PHONE: vi� CUNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT ❑ AG ❑LEA EXEMPT ❑COMMON CARRIER DRIVER'S LIC#: I certify 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 that falsification of this information may result in sus- pension,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 adminis- ative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. — —? - � Driver's Name(Print) Driver's Signature Date Part 4: Other Information(Golden By-Products in-house use only) LOG#: L J- �� L/ WEIGHT CERT#: NET WT: For the other half of this transaction,hauler is also the: 11 Generator !IEnd use facility MANIFEST#: M - - — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — iGoiden's other half of transaction# Other EDT Hauler EDT Manifest# IPaper Manifest#in place of Goldens EDT Manifest# for: (circle one) Pick-up Delivery 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 ri0 Data 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 u`o ' rp this information,I request that CIWMB contact me at the address and telephone number above. N m m 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. F020404