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GOLDEN BY-PRODUCTOba SCRAP TIRE COMPAQ <br /> P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314- 10/23/2013 RC — 1_ EDT MANIFEST#: 1003314- 00092337 <br /> DATE DRIVERS[NIT RUN# <br /> SHIP TO: ACCT#: 53MZJM BILL TO: w TERMS: NET15 <br /> J M EQUIPMENT J M EQUIPMENT <br /> 321 SPRECKLES 321 SPRECKLES <br /> MANTECA, CA 95336 MANTECA, CA 95336 <br /> TPID# 1623726-01 <br /> PHONE: (209)495-1118 PHONE: (209)495-1118 <br /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD, BALLICO STATE CA <br /> TRUCK#: GBPO86 LIC PLATE#: CA 9B65297 DECAL# 13-01095 <br /> HAULER EXEMPTION: GOVT []LEA EXEMPT COMMON CARRIER UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: PU{t DEL <br /> (n i <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE-COUNT EA 1,30 <br /> TRUCK TIRE-COUNT EA 7.50 <br /> 2117 1 <br /> PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL BE SENT! <br /> Invoices over 30 days are subject to a late fee of 1 1/2% per month, <br /> which is 18% annually, or a minimum of$1.00 per month. TOTALk�� <br /> 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 <br /> 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. <br /> X X <br /> Facility Representative's Name(Print) Facility Representative's Signature Date <br /> \J I CHARGE [:] PAID CK# <br /> WEIGHT CERT NET WT TONS <br /> I certify that under penalty of perjury under th"ws of the State of Ca4fornia that Ole information provided above is true and cofrect In addition,I am award that falsification of this information <br /> may result;n suspens-on,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result.q civil penalties up to <br /> $25,000 pet day per violation or adminisiro6o pejfallies up to$5 000 per violalion per day as described in Public Resources Code section 42962. / r <br /> v'(+`, <br /> Signature Date <br /> C...: $) <br /> Deiv is m <br /> Nao(Print) Driver i' <br /> r ` <br /> 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 <br /> ria Dafq T confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> of this information,I request that CIWMB contact me at the address and telephone number above. <br /> w = Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to participate 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 CIWMB all required <br /> information from this manifest form. <br /> Customer <br />