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.:::::..... <br />ti :s:ii ii•.0 <br />-:sS'.-::.-:-.: �.`� •.11LSS�..... ... ... .. •:_..�_':;-_�.__.• _ - - .... ....-_-- <br />.::..:: ::..:.:... <br />SOL -DEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br />P.O. BOX 1 / 13000 NEWPORT RD. INVOICE <br />BALLICO, CA 95303 (209) 668-4855 <br />EDT TRIP LOG #: 1003314- 1111_ 4/2012 JA <br />DATE DRIVERS INIT RUN # <br />SHIP TO: ACCT #: 11GZST <br />STOCKTON WHEEL <br />648 W. FREMONT ST <br />STOCKTON, CA 95205 <br />TPID # 1670776-01 <br />PHONE: (209) 464-7771 <br />HAULERISHIP VIA. GOLDEN BY-PRODUCTS <br />TRUCK #: <br />LIC PLATE #: CA9E38698 <br />HAULER EXEMPTION: GovT LEA EXEMPT <br />EDT MANIFEST #: 1003314- <br />BILL TO: TERMS: <br />STOCKTON WHEEL <br />648 W. FREMONT ST <br />STOCKTON, CA 95205 <br />PHONE: (209) 464-7771 <br />13000 NEWPORT RD. <br />12-07987 <br />DECAL* <br />BALLICO <br />00084792 <br />COMMON CARRIER R UNREGISTERED HAULER <br />SPECIAL INSTRUCTIONS: <br />DEL <br />CHARGE [] PAID CK# <br />T CERT 62801 NET WT 3.70 TONS <br />NETO <br />STATE CA <br />TOTAL F7:— 630.00 - <br />WEIGH I am aware that <br />I certify that result in ndspensionnaltYof perjury revocationuorddenhallof enof the State ewal of theof CalifornWaste Tire Hauia tler Regthe l trration pursuant suantt t Public Resouration provided above is true ces Code sect ocorrect. In dn1t42960 and may result inlcivllpenaon flGe's up mation <br />may r penalties u to $5,000 per violation per day as described In Public Resou1. rces Code section 42962 <br />$25,000 per day per violation or administrative p, P {, - <br />X Date <br />Driver's Signature <br />Driver's Name (Print) <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 />ti� Darq 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 />moo av of this information, I request that CIWMB contact me at the address and telephone number above. <br />N <br />w � m Electronic Reporting to CIWMB: Golden By -Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT <br />•, <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 />rt tQ.tnmpr <br />