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G I :DEN 13Y-PR0DU(t&ba SCRAP TIRE COM Y <br />P.O. BOX 1 / 13000 NEWPORT RD. <br />BALLICO, CA 95303 (209) 668-4855 <br />INVOICE <br />EDT -RIP LOG #: 1003314- 04/10/2008 JH 1 I EDT MANIFEST #: 1003314- I 00055359 <br />DATE DRIVERS INIT RUN # <br />SHIP 70: ACCT #: <br />LA-THROP CITY MAINTENANCE YARD <br />/57-t67T F STREET <br />LATHROP, CA 95330 <br />2VZLAT BILL TO: TERMS: <br />LATHROP, CITY OF <br />16775 HOWLAND RD #1 <br />LATHROP, CA 95330 <br />TPID # 1302978-01 <br />HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. <br />TRUCK:: GBP195 LIC PLATE #: 6F63879 DECAL #: 08-05558 <br />HAULER EXEMPTION: <br />EIGOVT F-] LEA EXEMPT F] COMMON CARRIER F] AG F-] UNREGISTERED HAULER <br />SPECIAL INSTRUCTIONS: <br />TRAILER: PU DEL <br />BALLICO <br />NET30 <br />STATE CA <br />TYPE <br />COUNT U/M <br />UNIT PRICE EXTENDED AMOUNT <br />PASSNGER TIRE <br />EA <br />1.50 <br />TRUCK TIRE <br />2 EA <br />8.00 <br />7` <br />E <br />0 2 <br />If <br />ra-'S ►tit �S S. <br />e, <br />L Fro rv, — <br />TOTAL <br />PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENTI <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 />Facility Representative's Name (Print) Facility Representative's Signature f Date <br />1 <br />LJ �.nr,r<v� u rrilu <br />WEIGHT CERT <br />NET WT <br />TONS <br />1 certify that under penally 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 suspension, 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 <br />$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 />Driver's Name (Print) Driver's Signature Date <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 />r,G DQtQr 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 />`° 'oy of this information, I request that CIWMB contact me at the address and telephone number above. <br />w •'4 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 />