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:._.: <br />i' = _ _ ------------- <br />" = — <br />--- _.: _11.1i�1S.-5:_:•i sem.•.. _:._. _�.' <br />GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPA <br />P.O. BOX 1 113000 NEWPORT RD. IN <br />BALLICO, CA 95303 (209) 668-4855 <br />EDT TRIP LOG #: 1003314- 04/18/2013 RC — <br />1 <br />DATE DRIVERS [NIT RUN # <br />SHIP TO: ACCT #: 11 GZST <br />STOCKTON WHEEL <br />648 W. FREMONT ST <br />STOCKTON, CA 95205 <br />TPID # 1670776-01 <br />EDT MANIFEST #: 1003314 - <br />BILL TO: <br />STOCKTON WHEEL <br />648 W. FREMONT ST <br />STOCKTON, CA 95205 <br />PHONE: (209) 464-7771 <br />PHONE: (209) 464-7771 <br />HAULERISHIP VIA: 13000 NEWPORT RD. <br />GOLDEN BY-PRODUCTS <br />TERMS: <br />BALLICO <br />VOICE <br />00087794 <br />NETO <br />TRUCK #: GBP086 LIC PLATE #: <br />CA 91365297 DECAL* 13-01095 <br />COMMON CARRIER UNREGISTERED HAULER <br />HAULER EXEMPTION: GOVT LEA EXEMPT �PFCIAL INSTRUCTIONS: <br />TRAILER <br />DEL <br />PU . ? ', r <br />„^r <br />STATE CA <br />TOTAL 540.00 <br />CHARGE PAID CK# <br />WEIGHT CERT <br />NET WT 3.60 TONS <br />to Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to <br />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 />I Y429 <br />fl fl <br />may result in suspension, revocation, or denial of renewal of the s ! € r <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 42 �62� f t E <br />4 Date <br />Driver s.Signature ; <br />Driver's Name (Print) P <br />ovided in Part <br />, Part <br />, and Part <br />I of <br />s form should be <br />ion <br />Co <br />nfidentiality Claim (applicable to all parties listed on above): 4 CCR, Setctionp17041 et seq slhould any member lof the public request disclosure red <br />rc Dat4 rr confidential, proprietary, and/or trade secret. In accordance with Title 1 , <br />of this information, I request that CIWMB contact me at the address and telephone number above. <br />v <br />• '�" Golden By -Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT <br />w - Electronic Reporting to CIWMB: <br />- electronic reporting program. On behalf of the customer listed on this form, Golden By <br />will electronically transmit to CIWMB all required <br />information from this manifest form. <br />(`I minmer <br />