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10/21/04 12:30 FAX 209 6674854G.B.P. 19001 A-rT IN f, f o S rV-5a S GOLDEN BY PRODL ;TS WASTE & USED TIRE .., ANIFESTIRECEIPT EDT TRIP LOG#: 1003314- �- �i - �! EDT MANIFEST#: 1003314—0 016470 -A DATE DRV INTL RUN# INVO JICE P Part 1: Facility Information (Actual physical location of facility) 1 t Check one: PICK UP FROM A GENERATOR C DELIVERY TO AN END USE FACILITY 5 If applicable: ❑Import ❑Export Imp/Exp Location: CD GOLDEN/STC ACCT#__ '1711!7 NAME: �}v / ADDRESS:��C " — �'" n TIRE PROGRAM ID: ADDRESS:, CITY,ST,ZIP: SITE SUFFIX: PHONE: T/Yt`% TRAILER#: P(U DEL. Part : Load Information TYPE COLDV RATE DOLLAR ❑USED TIRES Passenger @ _= QP- - Intended Use: . I.W HOLE WASTE TIRES Truck JPRODUCT @ _ ❑RETREAD Tractor @ - CYCLE ,*HOLE TIRE COUNT(C) Other @ _ -UEL CUBIC YARDS(Y) Trailer @ _ ❑DISPOSAL !--WEIGHT IN LBS(P) L WEIGHT IN TOTS(T) TOTAL cerdry,lhet under pe ty of perjury under Pte laws of the Stale of California.hal the Info-matlon provided�Fddi ve Is true end carmW. Ido ,I am net folvileallon of this Information may result In dull oenaltias up to E7 O rr day, rviola on or adminlstrativa penalties up to$5,000 per violation perday In Pohl c so ces ode 4296 /� CA 2 �. F tlity Representativ s Name(Print} Representative' ignature Date P tt33: Hau1Gr Information TRUCK#: _ 1 c STATE: CA NAME: Golden By-Products,Inc ADDRESS: P.O.Box lLIC PLATE#: _40 ADDRESS: 13000 Newport Road �p CITY,ST,ZIP: Ballico,CA 95303 GG/� 2 ` DECAL#: PHONE: (209)66811855 ��3 c — F7 UNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT ❑ AG ❑LEA EXEMPT El COMMON CARRIER DRIVER'S LIC#: i certify that under penally of Perjury under the ieweo`the State of California the.the infonvfion provided above is sue and correct.In addition,I am swam that tala4loedon of II inforrnatlon may result In sus- panslon.revccadon,or denial of renewal of the Waste Tina Hauler RepistraHon pursuant Ia Public Resources Code section 1.2960 and may result in UVI oenaltles up b$25.coo per day,per vloladon or adminls- tradv3 penaldsa up to$5,000 perviolallon per day as described In Public Resources Code section 42962, 4r (4f , Driver's Name(Print) onver-tiginatureO Date Part 4. Other Information(Golden By-Products in-house use only) LOG#:L - WEIGHT CERT#: _ ___ __ NET WT: _ __TONS For the other half of this transaction,hauler is also the: ❑Generator OEnd use facility MANIFEST#;M - - :iGolden's other half of hansaetien# JOther EDT Hauler EDT Manirest 7Paper Manifest#in place cf Qoldenc EDT Mani rest# for: (circle one) Pick-up Delivery yr Dato, CenNdenUallty Claim(applicable to all parties listed on above):The Information provided In Part I,Part II and Part III of this form should be considered coni �00 ry dential,proprietary,arri trade secret.In accordance wRh Tithe 14,CCR,Section 17041 at.seq,should any member of the public request disclosures of this information,I request that CIWIrAB contact me at the address and telephone number above. Electronic Reporting to CIWMB:Golden By-Products has been authorized by CIWMB to participate In the Waste and Used Tire Manifest EDT electronic reporting prcgram.On behalf of the customer listed on this form,Golden By-Produots will slecironloelly transmit to CII,NMB a$required information from this manifest form. Ha20494