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GULDEN BY-PRODUCTS dba SCRAP TIRE COMPANY P.O. BOX 1 /13000 NEWPORT RW INVOICE BALLICO, CA 95303 (209) 668-4855 r-OT TRIP LOG#: 1003314- 11/01/2012 JA 1 EDT MANIFEST* 1003314- 00083807 DATE DRIVERS INIT RUN# SHIP TO: ACCT#: MILLER BILL TO: TERMS: NETO MILLER ENVIRONMENTAL MILLER ENVIRONMENTAL 11213 S. HWY 99 2210 S. DUPONT DRIVE FRENCH CAMP, CA 95231 ANAHEIM, CA 92806 TPID# NEED#-01 PHONE: (714) 385-0099 PHONE: (760) 834-5777 JOB#3133 HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA TRUCK#: GBPO85 LIC PLATE#: CA9655421 DECAL#: 12-04182 HAULER EXEMPTION: ❑ GOV'T F] LEA EXEMPT ❑ COMMON CARRIER UNREGISTERED HAULER TRAILER: PU DEL SPECIAL INSTRUCTIONS: TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT PASSENGER TIRE-COUNT EA 1.75 TRUCK TIRE-COUNT EA 7.50 PLEASE PAY FROM THIS INVOICE- NO OTHER INVOICES WILL BE SENT! 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 I certify[hal under penalty of perjury under the laws of the Stale of California that the information provided above is true and correct. In addition,I am aware that falsification of this information may result inF�vil penalties up to_$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. i Facility Representa0e's Name(Print) Facility Representative's Signature ~ Date CHARGE F—] PAID CK# WEIGHT CERT NET WT TONS I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct In addition,I am aware that falsification of this information may result in suspension,revocation, r denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil X p$nalties 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. J / � �� 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 II,and Part III of this form should be considered >°Dafgr 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. m ra 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