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GOLDEN BY-PRODUCT.. Jba SCRAP TIRE COMPAY P.O. BOX 1 / 13000 NEWPORT RD. INVOICE BALLICO, CA 95303 (209) 668-4855 EDT TRIP LOG#: 1003314- 08/13/2013 RC 1 EDT MANIFEST#: 1003314- 00090520 DATE DRIVERS INIT RUN# SHIP TO: ACCT#: 53MZJM BILL TO: TERMS: NET15 J M EQUIPMENT J M EQUIPMENT 321 SPRECKLES 321 SPRECKLES MANTECA, CA 95336 MANTECA, CA 95336 TPID# 1623726-01 PHONE: (209)495-1118 PHONE: 9) 495-1118 HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA TRUCK#: GBP086 LIC PLATE#: CA 9665297 DECAL#: 13-01095 HAULER EXEMPTION: FIGOVT F] LEA EXEMPT ❑ COMMON CARRIER F] UNREGISTERED HAULER TRAILER: PU DEL SPECIAL INSTRUCTIONS: TYPE COUNT UIM UNIT PRICE UTENDS MOUNT PASSENGER TIRE-COUNT EA 1.30 TRUCK TIRE-COUNT EA 7.50 PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENT[ Invoices over 30 days are subject to a late fee of 1 1/2% per month, o which is 18% annually, or a minimum of$1.00 per month. TOTAL certify that under penalty of perjury under the laws of the Stale of California that the information provided above is Irue and correct. In addition,I am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. X X Facility Representative's Name(Print) Facility Representative's Signature Date CHARGE ❑ PAID CK# WEIGHT CERT NET WT TONS I certify that under penalty of perjury under the laws of the Slate of California that the information provided above is true and Correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Coda section 42960 and may result in civil penalties up to $25,000 per day per violation or administrative penalties up to$5,o0o per violation par day as deschbod in Public Resources Code section 42962. X X : s/-3/1 Driver's Name(Print) Driver's Signature Da(e Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part il,and Part III of this form should be considered ��c P°tpT 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 this information,I request that CIWMB contact me at the address and telephone number above. 4 v d 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. Customer