Laserfiche WebLink
- -- _ . <br />a <br />- = _= =:=:_ __ =:.... <br />----- :: • ..... <br />............................. .....�:........................... <br />=: =:-------------- - <br />JOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY <br />P.O. BOX 1 / 13000 NEWPORT RD. <br />BALLICO, CA 95303 (209) 668-4855 <br />EDT TRIP LOG #: 1003314- — <br />DATE DRIVERS INIT RUNS <br />SHIP TO:C CT #: <br />S� Haw vw <br />f�, W. -tee,, nfl ' <br />"Y"a, C' 9 <br />TPID# 61 <br />PHONE: ji/- '7771 - <br />INVOICE Z%1 <br />INVOICE <br />EDT MANIFEST #: 1003314- 1 802297 <br />BILL TO: TERMS: <br />//!� tilt- W_-49PHONE: fj.1 767— 777 <br />HAULER/SHIP VIA: _ <br />TRUCK #. <br />LIC PLATE #: DECAL#: <br />HAULER EXEMPTION: GOVT [] LEA EXEMPT 0 COMMON CARRIER <br />SPECIAL INS <br />TRAILER: PU DEL �/�nfL L <br />STATE_ <br />UNREGISTERED HAULER O <br />IONS: nafferhf) <br />RN,IF651 IDC -,V 45 <br />11A//, <br />PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENT! <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. f <br />1 oerdfy and penally of perjwy under Otte laws el No Siete of Calil—it mal Noonation provided abo ais t ue as InsiX sd m'Publ R-t�Cod. oct,en 2%2mlumation <br />may resua in olvil ponaltioa up to 525.000 per day. per violation or adminis LW Ries �.p to $5.000 Per v s <br />X <br />XFacility Representative's Signature Date <br />Facility Representative's Name (Print) <br />CHARGE PAID CK# <br />WEIGHT CERT NET WT TONS <br />tler the laws of ew SUIa of C•57omia that tho information provided above Is twe aro Lorea In edditW, I am aware 4h3UaI5Trcatkn Of this iMarawllon <br />I c.ngy Ihet undtt penalty of perjury un Ito Public Resource Cade section 42950 may res, tin dvd ps i ies up 10 <br />may result' s ocebon, or deniol of renewal of the W ale <br />Tia lajlo r per <br />dayetion pursuan 7 , <br />C <br />sed�on a2 <br />325000 p ptt vmlation iniatrative panaldes up b OO perper violailoh per day es described in pur+lw Ras � <br />Da <br />Confidentiality Claim (aPPllcable to all pertie's listed on above): The information provided N Part I, Part II, and Part III of this form should be considered <br />Sic Dolor confidential, proprietary, andfor trade secret. In accordance with Title 14, CCR, Section 17041 etseq, should any member of the public request disUosure <br />_ g of this information, I request that CIWMB contact me at the address and telephone number above. <br />$ w <br />w _ Electronic Reporting to CIW M6: Golden By -Products has been authorized by CIWMB to paridpare in the Waste and Used Tire Manifest EDT <br />electronic reporting program. On behalf of the customer listed on Oils form. Golden By -Products will electronically transmit to CIWMB all required <br />information from this manifest form. <br />Original - Office Copy <br />