Laserfiche WebLink
HAP-6-2008 02:53P FP011:SEXT0N CHEOPOLET (209)824-9893 TO:4688392 <br /> GOLDEN BY-PRODUCI#dba SCRAP TIRE COMPX <br /> P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br /> BALLicd, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314- 01/07/2008 JH 1 EDT MANIFEST#: 1003314- 53444 <br /> DATE DRIVERS IN(T RUN 8 <br /> SHIP TO: ACCT M SEXTON BILL TO: TERM : NET30 <br /> SEXTON CHEVROLET SEXTON CHEVROLET <br /> 321 SPRECKLES AVE. 321 SPRECKLES AVE. <br /> MANTECA, CA 95336 MANTECA, CA 95336 <br /> TPID # 1300314-01 <br /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD, BALLICO STATE CA <br /> TRUCK# GBP193 LIC PLATE#: 6F63877 DECAL#: 07-07242 <br /> HAULER EXEMPTION: <br /> GOVT ❑ LEA EXEMPT []COMMON CARRIER ❑AG UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: PU DEL <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE r EA 1.25 <br /> FUEL SURCHARGE-ROUTE EA 0.0569 <br /> TOTAL :! <br /> PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL BE SENTI <br /> I cenrfy that under penalty of pariury under the laws of the State of California that the information provided @boys is true and correct, In addition,I am ewers Thai ialsification of this information <br /> may resuh m evil penalties up to 525.000 per day,Per vrolacon or administrative penalties up l0 15,000 pal violation par day as described In Public Resources Code section 42862 <br /> X <br /> Facility Representative's Name(Print) Fakifity,Representative's Signature ,1 Date <br /> (�'CHARGE LI PAID CK# <br /> /�� .41-- <br /> WEIGHT CERT NET WT TONS <br /> Al ")' 7 <br /> I certify,that under penalty of pariury under the laws of the State of California that the information provided above is true and fortedin addlion,,i am aware that I@Isdication of two blormation <br /> may resue In suspension,revocstion,or dental of renewal of the Waste Tale Hauler Redistrallon pursuant to Public Resources Coda seetlon 4299 and may result In civil peralties up to <br /> $25,000 per day per violation or edminisiralive pt)t Ies up to$5,000 per vlotellon per day es described In Public Resour Cod radion 42862 <br /> Driver's Name(Print) DrN'es Sigpstun Date <br /> Confidentlallty Claim (applicable to all parses Noted on above): The Information provided in Part I,Part II,and Part III of this form should be considered <br /> eovc Daro r, confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 eLseq,should any member of the public request disclosure <br /> 4 of this information.I request that CIWM8 contact me at the address and telephone number above. <br /> e <br /> Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to panfcfpate in the Waste and Used Tire Manifest EDT <br /> electronic reporting program. On behalf of the customer listed on this form.Golden By-Products will electronically transmit to CMlMB all required <br /> information from this manifest form <br /> Customer <br />