COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

10/21/04 12:34 FAX 209 6674854 G.B.P. Z005 GOLDEN BY PRODOTS WASTE & USED TANIFEST/RECEIPT EDT TRIP LOG#: 1003314-eQCIZ to y�- e-- -_�_ EDT MANIFEST#: 1003314--0 015304 -A DATE DRV INTL RUN# INVOICE# Part 1:Facility Information (Actual physical location of facility) ll J _;9_/ m Check one: VPICK UP FROM A GENERATOR ❑ DELIVERY TO AN END USE FACILITY If applicable: ❑Import ElExport Imp/Exp Location: c NAME: (./ GOLDEN/STC ACCT#: ADDRESS: /��ir �'j`'�?• -r RJ TIRE PROGRAM ID: ic ADDRESS: -��Z O^ x,326 4V• ��_ t ;� �®/ CITY,ST,ZI � SITE SUFFIX: �� I\) PHONE: TRAILER#: P/U DEL Part 2� Load Information TYPE COUNT RAE DOLLARS ❑USED TIRES Passenger @ . ?y*aW�v _ �_ Intended Use; 11HOLE WASTE TIRES LPRODC;CT: Tractor @ Tractor HOLE TIRE COUNT(C) = ❑CUBIC YARDS(Y) Other @ UEL ❑WEIGHT IN LBS I Trailer @ _ �� ❑DISPOSAL El WEIGHT IN TONS(T) TOTAL I eenlfy three u er pane ty o'penury aider the laws of the state of California thad the hYermation Wov clad above is t ue an arca n ad9tron,I am ewrere that f t of this infnrmation may result in elvil car, up ,ODO per day,pervolalfon or bketive penelties up to$5,D00 per vialad per day ee dacribed u secants Code vection 42 4CJ� Fac lity epresentative's Name(Print) tive's Signature Dell Part 3: Hauler Information TRUCK* _ e STATE: CA NAME: Golden By-Products,Inc. ADDRESS: P.O.Box 1 LIC PLATE ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA.95303 DECAL#: v► o► PHONE: (209)668-4855 ❑UNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT AG ❑LEA EXEMPT [I COMMON CARRIER DRIVER'S LIC#: I certify that under penalty of perjury under the lawn of the State cf Callfomla that the Information provided above is true anC correct.In addition,I am aware that fas 9cauon of this information may result in sus- penalon,revocatlon,or denial o`renewal of the Waite Tire Hauler RegieUaUon pursuant to Public Resourcee Code section g296D and may result in civil penalties up lo$25,000 pe,day,per violallo or adiri lratva penalties up to sti3Oo0 per violation per day as described In Public Resources code section 42962. Driver's Name(Print) Driver's Signal (I D Part 4: Other Information(Golden Bv-Products in-house use D&J LOG#:L - WEIGHT CERT#: NET WT: TONS ❑For the other half of this transaction,hauler is also the: ❑Generator ❑End use facility MANIFEST#:M - -B —Golden's Other half of transaction# Other EDT Heiler EDT Manifest ter 21'aper Manifest 4 in place of Golden EDT Manifest#for: (circle one) Pick-up Delivery �c Dofp Confidentiality Claim(applicable to all parties listed on above):The Inrormaden provided In Part I,Part II and Part III of this form should be considered tend. jos err denllei,proprialary,and/or trade secret In accordance with Title 14,CCR,Section 17041 stseq,shWo any member ofthe public request disclosure of this information,I request that CIWMB contact me at the address and telephone number above. ve y Meetronlc Reporting to CIYVMB: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-Prodtcta will electronically transmit to CIWMB all required information from this martifast form. 1-1020404