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.: <br />......:, <br />3JOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br />P.O. BOX 1 113000 NEWPORT RD. INVOICE <br />BALLICO, CA 95303 (209) 668-4855 <br />EDT TRIP LOG #: 1003314-71:�t <br />DATE DRIVERS INR RUN 8 <br />SHIP TO:CT #: <br />S7acK0& 611�_�L <br />'SyV44VDn <br />TPID# L[p7077/,-� <br />PHONE: �%a 9Ll ,V '771 <br />EDT MANIFEST#: 1003314- 1 802297 <br />BILL TO: TERMS: <br />c57A'L�y lVfl�L�i <br />PHONE: <br />HAULERISHIP VIA: <br />TRUCK M LIC PLATE #: DECAL #: <br />HAULER EXEMPTION: n GOVT [] LEA EXEMPT 0 COMMON CARRIER I I UNREGISTERED HAULER D <br />SPECIAL INSTRUCTIONS: <br />TRAII FR• PU DEL A4pp r .2A,.3 <br />STATE_ <br />PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENTI <br />Invoices over 30 days are subject to a late fee of 1 112% per month, TOTAL <br />which is 18% annually, or a minimum of $1.00 per month. <br />I certify panty of perjury under cite laws of the State of California that I nfotmatito provided above is We and MCL In edditioR I em a that lelslliwllon of this mrtn <br />foalion <br />may msua n civil poratties up to $25.000 per day, per violation or administrative p Idea -P to $5,000 par "olation Dor d as desvibed in Pubbc Resowccs Code section 42992 <br />X's Signature Date <br />Facility Representative's Name (Print) Facility Representative <br />CHARGE PAID CK# <br />WEIGHT CERT <br />NET WT TONS <br />I cer* Viet LaMar pena0y or Perjury undw the laws of the State of C.R.—ia toot iho iNwme103 provided above is R and corrode In ti o 429 i am aware N ult.n pal'pn penalties up to alro't <br />may result' s capon, revocation, or decrial d renewal at iha Waste Tire Heu11r Registration pursuant to Pubiw Resource Code section 42960 may res pen -7 <br />$25,000 peer violadoninisvative penalties p a I Ixr notation oar day es describod in PWIic Re Code section 429 -//i�y1i' <br />Da <br />licable to all Parties listed W above): The information Provided in Part I, Part II, and Part III of this form should be Considered <br />Confidentiality Claim (app <br />M`o Dale T Confidential, proprietary, andfor trade secret In accordance with Title t 4, CCR, Section 17041 etseq, should arty member of the public request disclosure <br />o� of this Information. I request that CIWMB contact ma at the address and telephone number above - <br />o Electronic Reporting to CIWMB: Golden By -Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT <br />electronic reposing program. On behalf of' the customer listed on this form. Golden By -Products Wil electronically transmit to CIWMB all required <br />information from this manifest form. <br />Original - Office Copy <br />