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S O Ste:•:_ '_=:L�S:::1 i � .f• vwwv.: 1' -_� _':�_:::�: <br />GOLDEN BY-PRODUCTS dba SCRAP TIRE COMPANY INVOICE <br />P.O. BOX 1 / 13000 NEWPORT RD. <br />BALLICO, CA 95303 (209) 668-4855 <br />EDT TRIP LOG #: 1003314- 07131/2013 EDT MANIFEST #: 1003314- 00090260 <br />DATE DRNERS INIT RUN # <br />SHIP TO: ACCT #: BILL TO: TERMS: NETO <br />11 GZST <br />STOCKTON WHEEL 648 W. FRETON WHEEST <br />L <br />648 W. FREMONT ST 648 W. TON, CA 9 20 <br />STOCKTON, CA 95205 STOCKTON, CA 95205 <br />TPID # 1670776-01 <br />PHONE: (209) 464-7771 PHONE: 1209)464 <br />HAULER/SHIP VIA: GOLDEN BY-PRODUCTS .13000 NEWPORT RD, <br />BALLICO STATE CA <br />(TRUCK #: G LIC PLATE M DECAL #: J <br />HAULER EXEMPTION: GOVT F] LEA EXEMPT F] COMMON CARRIER 0 UNREGISTERED HAULER <br />SPECIAL INSTRUCTIONS: <br />TRAILER: PU DEL CORRECTION FOR TIRES DELIVERED IN 2013 <br />.. rncn naaf111A1T <br />TOTAL <br />I anify that render perelry or perjury under the laws of tho SWIe Of California that the Mformahon provided abnveis l on ar tla nanda cribodIn tln Publ c Rasourc» Cfodo sea�on d29 2�nrormaticn <br />moy result in civil p_1t;as up to 525,000 pw day, par vwlation or administrallve pmelties up to 55.000 par <br />v a i pe y as <br />XFacility Representative's Signature Date <br />Faclltry Representative's Name (Print) <br />F] CHARGE F] PAID CK# <br />WEIGHT CERT <br />NET WT TONS <br />I rxmyy (hal rawer penalty of perjury under the laws of era State d Cai if (hal the informollon provided above is true and cornet M Wditbn, 1 con ewer' that fa""i ,slbn.1Ih1s "Via - <br />may r.sull M on, rev.. nlm. w derval or renewal 01 the West. Tire R..�er R.9ist'.li. pursvaM to Public R owces Code sradion 42960 acrd rney result M civil penalties up to <br />525.000 par violation w admirrisaative penalties up to 55,00 par v',dalion per day as daswibed in Public rjegoutx5 Coda section 42Si62. <br />XDriver's Signature ' Date <br />Driver's Name (Pring <br />Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I, Part 11, and Part III of this form should be considered <br />o �c D.1, ' confidential, proprietary, and/or trade secret In accordance with Tittle 14, CCR, Sector, 17041 el.seq, should any member of the public request disclosure <br />o of this information. I request that CIWMB contact me at the address and telephone number above. <br />N ElectfonlC Reporting to CIWMB: Golden By -Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT <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 toren. <br />Original - Office Copy <br />