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10/21/04_ 12.:31 FAX 209 6674654 G.B.P. 1 002 GOLDEN BY PRODOTS WASTE & USED TIRE_ ANIFEST/RECEIPT EDT TRIP LOG#: 1003314- �I_ ./_05(-4RV_5�t_ - - I EDT MANIFEST#: 1003314—0 016107 -A DATE RUN# iCN}VOICED Part 1:Facility Information (Actual physical location of facility) 7 r D a 1 1 Check one: ❑ PICK UP FROM A GENERATOR ❑ DELIVERY TO AN END USE FACILITY If applicable: ❑Import ❑Export Imp/Exp Location: DC7 DEN/STC ACCT#:a i -r.S Q A— NAME: —rrar-v -TfRe graa Qc6p., ADDRESS: SPPROGRAMID: ,CO ADDRESS: 3AG We G•ra.n T L-!NE — CITY,ST,ZIP: TV aC y CI Ae Q537 6 Q p SITE SUFFIX: PHONE: TRAILER#: P/U DEL Part 7- Load Information TYPE COUNT RATE DOLLARS ❑USED TIRES Passenger f 3 G 46 Intended Use: AWHOLE WASTE TIRES Truck @ ❑RETREAD CIPRODUCT: Tractor = WRECYC/WHOLE TIRE COUNT(C) Other OFUEL @ _ LE CCUBIC YARDS(Y) @ - ❑FUEL ❑WEIGHT IN LBS(P) Trailer @ - 1�2� 0 ❑DISPOSAL [:WEIGHT IN TONS(T) TOTAL oedify that under penalty of per)ury under the lawn of the Slate of CalHcmia that the information provided above Is nd co .In addalon,I am aware that f aloe this Information may result in civil pens,peer uR to 525.000 par per vtota n or adrNNstrauve penalties up to 55,000 per violation per day as deae b P c Resourese node eaten I I Facility Representative's Na (Print) Facility native's Signature Date Part 3: Hauler Information TRUCK#: — — STATE: CA NAME: Golden By-Products,Inc. rA I �� ADDRESS: P.O.Box i Y P (1�;{C LIC PLATE Q —k a jz ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 f QO:� DECAL#: Q p sir Q Q PHONE: (209)668-4855 ❑UNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT ❑ AG ❑LEA EXEZ PT ❑COMMON CARRIER DRIVER'S LIC#: I cerlify that under penalty of perjury under the laws of the state of California the'the information provided above is true and correct.In add don.I am aware that ralslflcation of this Information may result in sus- pension,ravwation,or denial of renewal of the Waste The Heuer Registration pursuant:o Public Resources Code section 42960 and may result in dvil,penalties up to$26,0100 per day.per viotalicn or adminis- iry+�y{ponailias up to$5000 Plb4ftn po-day as described In Public Resources Code sectlon 42962. .i rnA C On rTe C k 1w r!`t Ina � t!�t�S: 10-6--ow D •ver's Name(Print) Driver's Signaturc Date Part 4: Other Information(Golden By-Products in-house usepart 4: Other Information Products in-house use only) LOG#:L — WEIGHT CERT#: ————— — NET WT: _TONS LFor the other half of this transaction,hauler is also the: CGenerator End use facility MANIFEST M M — - ]Golden's other half cf transection# JOther EDT Hauler EDT Manifest# JPaper Manifest I in place of Geldena EDT Manifest# far, (circle one) Pict-up Delivcry parves on in 1,Part Part III of 6 DatQ ConfidentrrV dent al pr0lality prletaryl�and(otrade secretim(sopucalbe to !Inaccordanee weh Tb 14eCCR Information eflon 170d41�st.segrtehould!any member of hespubl�request dlecbeuereeof thisnfi- information.I request the:CIWMB 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 program.On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required Information from this rnanl'estform, FMCd04