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12/01/2005 14:37 12098361917 THE SERVICE STATI01`4 PAGE 02 <br /> GOLDEN BY PRODOTS WASTE & USED TII4VIANIFEST/RECEIPT <br /> EDT TRIP LUG 4: 10033]4-Com/ /��IG - _� - "I r T�I)T MANIFEST #i: 1003314—0 030880 -A <br /> D\Tl; I)IZV fN 11. RI IN ii INVOICE f! <br /> Part 1: Facility Information (Actual physical location cif facility) <br /> C'hcck onc: ' 1?JIJCK l-JP FROM A GENERATOR I 1 DFTWERY TO AN l;ND UST? FACILITY <br /> If applicable: i-Lmrort i Export Imp/l-Ap Location: <br /> 601_,T)FN/STC ACCT4: <br /> --- - - - - - - <br /> ADDRFSS: w, //x� 1.11u,PR�GRnTvr Tri: <br /> ADDR]:�SS: — — — — — — <br /> CITY.ST.ZIP: ri_.�v' C- ! r SfIL SUFFIX: <br /> PTTONF.: ter' S , — — <br /> 7IZ-�ILl:at#: PIrJ DEL. <br /> Part-1 Toad Information TYPE COU T RAT3 �5 DOL QRS <br /> Passenger / /@ �- Intendl;d Usc: <br /> fI:WHULli WAS'1'l.;TIRES <br /> fl.IPROT)UCT: Truck y @ - 1IRFTRP-,AD <br /> Tractor @ = IKkR_,CYCT.F. <br /> (Y) <br /> WHOLE TIRE: (L) Other � - JEL <br /> ' ��ICUBIC YARDS(Y) _ <br /> i,IWF..I0TTT IN LBS(P) Trailer �@ / I DISPOSALn WEIGHT IN TONS('t') TOTAL <br /> I cenlry lhgt!order)?natty or p?rJury undar rhe lame of Ihn$tarn of Cal�forn,a that the utfc—otiem provided above Is true and correct In BOcriim. ,I am awara than fal,ficalion of this ofcirmstion may result In civil <br /> iwaliles up to$25,000 per diff,per-I019Von or admlmsrrgtN?p9naltb6!ip in'1(,.()00 per volition per day as described in Public Regoumes COOe sect Ion 42W­2 <br /> I _ <br /> I m;ility Rcprowntntivc-s Namc(Pnnt) ncilit\ RclirccenLttive'v Segrtatun Detc <br /> fart 3. Ilaulcr Information <br /> TRUCK#: � STATE-:: CA <br /> NAME: Golden Bv-Products.Inc. <br /> ADDRESS: P.U.Box'I LIC PLATL#: �j—�j„:S2 2 f <br /> ADDRESS: 13000 Ncwpon Road <br /> (:TTY.ST.ZIP: 13a11lico.CA 95303 DECAL#: <br /> PT-TONE: (209)669-4855 — �- <br /> I IIJNRFG1STFRED HAULER <br /> HAULER FXFMPTTON: 1100VT I I AG I ILFA rxi:MPT 11COMMON CARRIER DRIVER'S LIC* <br /> I cnn,fy that undar panatty of p?riury ander the law,-of rh?Stele of Califomrg that the mforme?Ion)mvld9d Mova*toor And rorrao In gddilori,I am a—im thio fnlsrficat,on of thy;nformw,an m0y result in iu!- <br /> p?nolon,r?l or carol of r���e���evraI Or Ing VV le Tire Hauler Replslrstlon pursuant to Public Resouroes Code aetllon 42960 grid rriq result in cNll penaltl?s uo ro E2'.000 par day,par violation ar adminis- <br /> trative pensllies up to S5.000 per vidaii0n`per dJy o:described n Public Rc"urce Cod!soction 422962. / <br /> nrivcr'c Nama(Print) <br /> Pan 4: Other TntimnationM(C,olden $v-Products in-1louse use only <br /> LU(; #: L - WFT(;TTT CT?.R.T#: NETWT: TONS <br /> '1For the tither half 4this transaction,haulcr is also the: I'IGcncrator 11End use facility <br /> NIANIFLST#: M - _13 <br /> Gnldcn's other half of rrnnaactinn is II)ih r:r LJ)f I Iauler fU f hlnnil'e<t d' I Pnj+cr hlanifcsl H in place nFGnldon<I'D I'Mrrmfcst'i fe+r (oirulc Anel ii lkhvu:n <br /> DCtp Confidentiality Claim(applicable to all parties Asted an above):The Information provldod In Part 1.Par(II and Part lit Of this form should be considered conf'- <br /> SO ♦ denw proprietary,and/or trade secret.fn accordance wrath Tale 1 d,CCR.Sgclion 17041 elSPQ.Sh0(ild any member of the Dublie request disclosure of this <br /> information,I request that CIWMB contact rrre at the address and telephone number above. <br /> n" Electronic Reporting to CIWMB:Golden By-Products has been authorized by C•WMB to participate In the Waste and Used Tire Manlresl III electronic <br /> ' reporting prograrl.Or bCh811 Of th6 CuStOrrt9r Ii5t9d on this form.Golden By-Products wilt electronically tranemit to CIWMB all required information from this <br /> manifest form. <br /> afnZnnnq <br />