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i j G DEN BY-PROBWTS WASTE & USED 70k MANIFESU"CEIP1 EDT TRIP LOG#: 10033144/1�7/ _ - EDT MANIFEST#: 1003314-0 020815 - DATE DRV INTL RUN# INVOICE# Part 1: Facility/Inforrnati (Actual physical location of facility) Check one: ICK UP FROM A GENERATOR FJ DELIVERY TO AN END USE FACILITY If applicable: El Import FlExport Imp/Exp Location: NAME: Golden By-Products, Inc. GOLDEN/STC ACCT#:__I_;� kz PT. ADDRESS: P.O. Box 1 TIRE PROGRAM ID: 1003314 ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 SITE SUFFIX: 01 PHONE: (209)668-4855 TRAILER#: PIU DEL Part;: Load Information TYPE COUNT RATE DOLLARS C JSED TIRES Passenger /7t' @ @ _ / LWHOLE WASTE TIRES --��11Z_ Intended Use: uPR J)UCT: Truck @ _ 79 -- ❑ ZRETREAD HOLE TIRE COUNT(C) Tractor @ __ C4R£-'YCLE CUBIC YARDS (Y) Other @ _ 2— ❑FUEL ❑WEIGHT IN LBS(P) Trailer@Z—= DISP SAL LWEIGHT IN TONS(T) TOTAL I certify that unde nalty of perjuryunder t e ws of the State of California that the information provided a ve' rue and correct.In d'ion,I am aware hat falsification of this or tion may result in civil penalties up to$ .000per day,per violatio administrative penalties up to$5,000 per violation per day a scribed in Public Reso es Code section 962. Facility Representative's Name(Print) acility Represen ative's Signature Vte Part 3: Hauler Information NAME: TRUCK#: _ _ _ STATE: AD RS: 0 ES4 lei TC LIC PLATE#: 6-41 ADDRESS: � i ` CITY, DECAL#:ST,Z P: !!� PHONE: ,t /�C l�c✓�(/ ��Q — — �� — — — — — HAULER EXEMPTION: ❑GOVT E AG ❑LEA EXEMPT ❑COMMON CARRIER UNREGISTERED HAULER DRIVER'S LIC #: I certify that unde 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,re ca n,or de al of rene al 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,p violation or aelminis- trative pena ' u to$5,0 0 per viol ion per day as described in Public Resources Code section 42962. / 7� J Driver's Name(Print) Driv is Signature ��,�e / i✓� Date Part 4: OtherInformation(Golden By-Products in-house use only) LOG#: L Z I—/7 /11 WEIGHT CERT#: _ _ _ _ NET WT: TONSI - JFor the other half of this transaction,hauler is also the: _iGenerator _]End use facility MANIFEST#: M - — — — — — — — — — — — — — — — — — — — — — — — — - -B Golden's other half of transaction# Other EDT Hauler EDT Manifest# IPaper Manifest#in place of Goldens EDT Manifest# for: (circle one) Pick-up Delivery to 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 ,Ts 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 v ¢y this information,I request that CIWMB contact me at the address and telephone number above. W 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