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GOLDEN BY-PRODUCTAba iSCRAP TIRE COMPA P.O. BOX 1 / 13000 NEWPORT RD. INVOICE BALLICO, CA 95303 (209) 668-4855 EDT TRIP LOG#: 1003314- 02/26/2007 EDT MANIFEST#: 1003314- 00046923 DATE DRIVERS 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 FRESNO, CA 93793 TPID# HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA TRUCK#: G LIC PLATE#: DECAL#: HAULER EXEMPTION: GOVT [—] LEA EXEMPT F� COMMON CARRIER AG UNREGISTERED HAULER SPECIAL INSTRUCTIONS: TRAILER: (PU 1 I DEL 1 _TYPE l J l COUNT U/M UNIT PRICE EXTENDED AMOUNT 45' TRAILER SERVICE 1.0000 EA 875.00 875.00 FUEL SURCHARGE-TRAILER I 1.0000 LOAD 40.00 40.00 � I � 1 j TOTAL 915.00 PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENT! I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct. In addition,I am aware that falsification of this information may result in civil penallies'up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. X X, " - . - Facility Representative's Name(Print) Facility Representative's Signature Date ❑CHARGE F] PAID CK# WEIGHT CERT NET WT 1.00 TONS I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to $25,000 per day per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. X1 1• - .. Driver's Name(Print) Driver's Signature Date Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part 11,and Part III of this form should be considered otic DafQ T confidential,proprietary,and/or trade secret..In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information,I request that CIWMB contact me at the address and telephone number above. U• j N w ':,. •, 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 listed on this form,Golden By-Products will electronically transmit to CIWMB all required information from this manifest form. Customer