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10/21/04 12:32 FAX 208 6674854 G.B.P. 171003 GOLDEN BY PRODS WASTE & USED TIRE _ . ANIFEST/RECEIPT EDT TRIP LOG#: 1003314- Z79151c7el-�,�-_-�_ EDT MANIFEST#: 1003314-0 015 717 -A DATE DRY INTL RUN# �pINVOICE# Part 1:Facility Information (Actual physical location of facility) 7 y d �� Check one, ,/SICK UP FROM A GENERATOR ` DELIVERY TO AN END USE FACILITY If applicable: ' ❑Import [.--j Export Irnp/Exp Location: GOLDEN/STC ACCT#: NAME: ADDRESS:�,e/ /re IRE PROGRAM ID, — ADDRESS: CITY,ST,Z SITE SUFFIX: PHONE: C�' ' `�/U1';. p TRAILER#: Pr'U DEL 5z Part Z: Load Information TYPE COUNT RAA DOLLARS L WHO TIRES Passenger@ _ Intended Use: WHOLE WASTE TIRES Truck @ ❑PRODUCT: _ CRETREAD Tractor @ - -RECYCLE OLE TIRE COUNT(C) Other@ UEL ;jCUBIC YARDS(Y) Trailer @ ! SPOSAL ❑WEIGHT IN LBS(P) UWEIGHT IN TONS(T) TOTAL _ I earthy that under I of pKury under the laws of the State of calllornie that the Infortratlon provided above Is true and ccnect.I dd a II ralsnlcatlon of thio I mat ey result In civil P Itiea up b per day,per•olatbn or iniairellve penallies up b SS,670 per violation par day ea desvlbed inPublic R Al Facility Roprosen vc'e Name(Print) Facility Representative's Signeture Da Pan 3: Hauler Information TRUCK#: — �'(,/STATE: CA NAME' Golden By-Products,Inc. J,� pf�-g ADDRESS: P.O.Box 1 � LIC PLATE ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 � DECAL#: PHONE: (209)668-4855 El UNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT ❑ AG ❑LEAEXEMPT ❑COMMCNCARMMER DRIVER'S LIC#; I certify that under porety of perjury under the laws of the State of Callo'nia that the Information provleed above Ir true and eorrecl. n lion,I aware Ihatfalallicaton of this information may result In sus• pension,revocation,o-denial of renewal of the WasleTlre Hauler Registration pursuant to Public Resources code eseban 42960 a res eiA panahiae up la$25,060 payday,per violation or ad Ivo lrative penalties up to$S•000 per lotion day as described In Public Resources Code section 47952. Driver's Name(Print) Driver' urs ate Part 4. Other Information(Golden By-Products in-house use only) LOG#:L - WEIGHT CERT#: ______ NET WT: _ TONS J For the other half of this transaction,hauler is also the: UGenerator ❑End use facility MANIFEST#: M - - JGeeden's other half of transaction if 70ther EDT Hauler EDT Manifest# JPaper Manifest 4 in piece of Goldens EDT Manifest 4 for- (circle one) Pick-up Delivery c Dato Confidentiality Claim(applicable to all parties listed on above):The information provided'n Part I,Part I I and Part 111 of the form should be considered confl- yo� rrV dentlal,propdetely,and/or trade secret In accordance with Title 14,CCR,Sectien 17041 et.seq,should any member of the public request disclosure of[tie 0 Information,I request that CIWMB contact me at the address and telephone number above. IL a Electronic Reporting to CIWMB:Golder By-Products has bean authorized by CIWMB to participate in the Waste and Used Tire Manliest EDT electronic reporting program.On behalf ofthe customer listed on this form,Gelden By-Products will electronically transmit to CIWMB all required Information from this manifest form. 11020404