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GOLDEN BY-PRODUC a SCRAP`iii E COMPA P.O. BOX 1 / 1 NEWPORT RD. BALLICO, CA 95303 (209) 668-4855 INVOICE e EDT TRIP LOG#: 1003314- 03/03/2010 EDT MANIFEST#: 1003314- 00067725 DATE DRNERS INIT RUN# SHIP TO: ACCT#: 12QZLR BILL TO: TERMS: NETO LAWSON ROCK AND OIL LAWSON ROCK AND OIL 10848 S. HARLAN P.O. BOX 9899 FRENCH CAMP, CA 95231 FRESNO, CA 93793 TPID# 1474313-01 n ` PHONE: (209) 983-1024 ` PHONE: (559) 275-2221 HAULER/SHIP VIA: GOLDEN BY-PRODUCTS / 13000 NEWPORT RD. BALLICO STATE CA TRUCK#: G — 10L] LIC PLATE#: V 265,:8 DECAL*: HAULER EXEMPTION: ❑GOV'T 0 LEA EXEMPT COMMON CARRIER UNREGISTERED HAULER TRAILER: l (PUS 3O Z Q 1 (DEL_ SPECIAL INSTRUCTIONS: TYPE COUNT I U/M UNIT PF�jjIlCE EXTENDED AMOUNT 45'TRAILER SERVICE-105 CUBIC YARDS f 1.0000 EA �,0�0.00 1,050.00 W. - PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENTI Invoices over 30 days are subject to a late fee of 1 1/2% per month, which is 18%annually, or a minimum of$1.00 per month. TOTAL 1,050.00 I certify that under penalty of perjury under the Iews of the Stale of California that the information provided above Is true and correct In addition,I am aware that falsification of this hrormation may result in civil penalties up to 525,000 per day,per violation or administrative penalties up to 55,000 per violation per day as described in public Resources Code section 42962 Facility Representatdve's Name(Print) Facility Representative's Signature Date f5�CHARGE PAID CK# WEIGHT CERT NET WT 1.00 TONS I 1 certify that under penalty of perjury under the laws of the Stele of Callnmia that the information provided above is true and correct. in addition,I am aware that falsification of this Information I may resue in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration Ptueuarft to Public Resources Code section 429W and may result in civil peneltles LP to $25,000 Per day per vlolaaon or administrative Penames uP to$5,000 per violation per day as described in PubNc Resources Code section 42962. Driver's Name(Print) Driver's Signature Date I Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part It.and Part III of this form should be considered confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 etseq,should any member of the public request disclosure ° p of this Information,I request that CIWMB contact me at the address and telephone number above a G i 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 fisted on this form,Golden By-Pro ducts will electronically transmit to CIWMB all required Information from this manifest form. I _ Customer i 1