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10/21/04 12:33 FAX 209 6674854 G.B.P. Ig004 <br /> GOLDEN BY PRODOTS WASTE & USED TIRE. _.. ANIFEST/RECEIPT <br /> EDT TRIP LOG#: 1003314-_/ 1 /__ Com'- EDT MANIFEST#: 1003314-0 015560 -A <br /> DATE DRV INTL N �IINV1OICE# <br /> Part 1:Facility Info*ImportCExport <br /> (Actual physical location of Facility) <br /> Check one: K UP FROM A GENERATOR ❑ DELIVERY TO AN END USE FACILITY <br /> If applicable: Imp/Exp Location: 3T`f2-c If <br /> GOLDEN/STC ACCT#:I+ EZ-f,P <br /> NAME: -rwyL.f -V <br /> ADDRESS: /, ,,, / TIRE PROGRAM ID: — <br /> ADDRESS: �0'�1`-T N'rK- <br /> CITY, ST,ZIP: SITE SUFFIX: <br /> PHONE: tv <br /> TRAILER#: P/U DEL O <br /> Pa 2: Load Informatiun TYPE COUNT RATE DOLLARS <br /> WHOLE IRES TIRES Passenger �@ q4 = �/S. `�4 Intended Use: <br /> Truck <br /> (]RETREAD[,-PRODUCT: @ - (]RETREAD <br /> Tractor @ - CYCLE <br /> U HOLE TIRE COUNT(C) Other @ = UEL <br /> CICUBIC YARDS(Y) <br /> ❑WEIGHT IN LBS Trailer @ _ ❑DISPOSAL <br /> ❑WEIGHT W TONSS(T) TOTAL <br /> 101,rd tF t r penally erJu under the levr f the State of ie et the information provided Zj <br /> In adds ,Is were a of this Infonnulle in civ I <br /> ,anal u 325,000 da r tlan or irtls a De ins up �'SA041'lion per day sour C 2 <br /> Facr epresentauve's I,/ <br /> e /v' esattativ Signature Da <br /> Part 3: Hauler Information TRUCK#`: — — STATE: CA <br /> NAME: Colden By-Products,Inc. � � � <br /> ADDRESS: P.O.Box 1 LIC PLATE#: <br /> . f— <br /> ADDRESS: 13000 Newport Road -Pm dizo <br /> — <br /> CITY,ST,ZIP: Balliw,CA 953031 � DECAL# — — — <br /> PHONE: (209)668-4855 E <br /> ❑UNREGISTERED HAULER <br /> HAULER EXEMPTION: ❑GOVT I AG ❑LEA EXEMPT ❑COMMON CARRIER DRIVER'S LIC#; <br /> I certify that undotpenaltyof perjury uALNeof theAHauler <br /> that the information provided above is true qqd i i add' amawthatfalalficalion of the Int s neuc- <br /> pensior,revocatl or ren elir OLI1c Resources Coce sec a 'ma re3ut n civil penallle9 up to$25,000 Derd err @dr➢llis- <br /> l•etive penaltlee e Code eeolion 42962. <br /> Driver's Name(Print) Driver's Signature Date <br /> Part 4: Other Information(Golden By-Products in-house use only) <br /> LOG#:L - WEIGHT CERT#: ______ NET WT: _ TONS <br /> C For the other half of this transaction,hauler is also the: ❑Generator DEnd use facility <br /> MANIFEST#t:M - -B <br /> Golcien's other half of transaction# JDtltcr EDT Hauler EDT Manifesto 7Paper Manifest k in place of Goldens EDT Manifest tl for: (circle one) Pick-up Delivery <br /> Confidentiality hould be considered oonfl. <br /> `orve DatQ r�� dental,prop etaryaand il <br /> /ortrade secret In accordance with Title to all peruse listed on abovee R 14,The Sec this <br /> on 17041 et.seq,should any member of the public srequest disclosure o sure this <br /> Informatlon,I request that cims contact me at the address and telephone numtoer above. <br /> Electronic Reporting to CIWMB:Golden By-Products has been authorized by CIWMB to perticlpete in the Waste and Used Tire Manifest EDTelectroric <br /> reporting program.On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required information from this <br /> manifest form. <br /> Ha2,)4o4 OCTENVIW <br /> 2 5 2004 <br /> PERM1�,�'t• ;;tl��j <br />