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02/26/2005 01:13 FAX �]0:1 VVI-1l r. IDL Ut'r.11 i xnr, iyiAnir r.' 3 l/1C�l JV ... 1 Q EDT TRIP LOG#: l003314-3_/_1_/_0q- n p _- i EDT MANIFEST#: 1003314-0 D 0 V r DATE DRV INTL RUN It INVOICE: Part l: FacilityInlormatib (Actual physical location of facility) Acct-4 itc 7 Check one: %,'Pl K UP FROM A GENERATOR DELIVERY TO AN END USE FACILITY , If applicable: I ort I Export Imp/Exp Location: GOLDEN/STC ACCT#: NAME: C ITADDRESS. i OF ATE1RbP — — — —,- — ST, CEtiti TIRE PROGRAM ID; ADDRESS: ~5-755 Th — ` — — _ — - CITY, ST,7lP:iL 912--000H�1Q6p CA. �330 SITE SUFFIX: Q PHONE:2 - _ TRAILER#: P/U DEL Part 2: Load Information TYPE COUNT RATE DOLLARS USED TIRES Passenger 23 _—@ 1,, 2.5 = It03 • Intended L WHOLE WASTE TIRES Truck 2 _ 1 I-{ PRODUCT: �, 00 — Tractor _ RETRE. % ^HOLE TIRE COUNT(M) — p "ECYC CUBIC YARDS(Y) Other RI M5 2 ��•' -- yFUEL WEIGHT IN LBS(P) Trailer @ - DISPOS WEIGHT IN TONS(T) TOTAL - �' 5 I cadily that under penalty of perjury under 11 2 laws of the State of California If at the information provided above is true and ewmel.In addition,1 am aware Iha1 falsification of 11is information may r ri civil penalties up to S25,0Oo per day,per violaboi or administrative penalties up to S5,o0o per violation per day as dew-d in.P.{iy/41,i�c Reno Oda!"on 42962. � '- Facilifv Representative's Name(Prir FacF�Represcnlativc's Signalure Duc Part 3: Haulcr Information TRUCK#: — — STATE: NAME: Golden BYLI roducLti,Inc. ADDRESS: P.O.Box I LIC PLATE#; ADDRESS: 13000 New rt Roach CITY.ST-ZIP: Ballicu,C� 5303 DECAL#: PHONE: (209)668 5 i . UNREGISTERED HAt :R HAULER EXEMPTION: i GOVT AG LEA EXEMPT COMMON CARRIER DRIVER'S LIC#: I cerlfly that under penally of perjury under Ih i laws of the State of California that the information provided above is true and correct.In addition,I am aware that falaiRcaUon of this iriformation may it t sus- pension,revoralion•or denial of renewal of if e Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may resull in ovil penalties up to 525.000 per day,per viola for Iminis- Iralive penances up to 55.000 per violatim1r. day as described in Public Resources Code section 42962. LEY fie Drivers Name(Print) Driver's Signature Due i Part 4: Other InformationIden B -Products in-house use only) LOG#: L — — _ WEIGHT CERT#: — NET WT: TO" - -- For the other half of this t ansaction, hauler is also thc: Generator End use facility I MANIFEST#: M B ' ` Gulden'n of icr half ul tramccnion# UOkr F,DT Haulcr EDT Manifest# Paper Manifest 0 in place ol'Golaens EDT Manifest# for: (circle uuel Pick-up Deli, ;onfidentiality Claim(applicable o all parties listed on above):The information provided in Part 1,Part II and Part lit of this form should be consider confidential,proprietary,and/or tra a secret.In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disck :of this information,I request that CI B contact me at the address and telephone number above. Electronic Reporting to CIWMB: olden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT elec C reporting program.On behalf of th customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required information frc lis manifest form I inn l lo.;