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AMERICAN TIRE RECYCLING, LLC. INVOICE / MANIFEST 13001 NEWPORT RD.BALLICO,CA 95303 Remit Payment (209)667-TIRE(8473)TPID#1904316 1012 11t"street Suitee 1 1000 Modesto,CA 95354 13309 A PICK UP Date: { DRIVERS INT RUN# GENERATOR: TPID# �' BILL TO: SAME AS GENERATOR !1 f �7 5 I / 1 C,, Jo!, v/ r� NAME: NAME: �f ADDRESS: ADDRESS: 1 w. CITY: STATE:CA ZIP: CITY: STATE CA ZIP: ,'J7 PHONE: PHONE: TYPE CUBIC YARDS COUNT U/M UNITE PRICE TOTAL$ AMOUNT PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENT! TOTAL $ 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. CHARGE PAID CK# I certify that under penalty of perjury under the law of the state of California that the information provided is true and correct.In addition,Ian)aware that falsification of this information may result in civ[I penalties up to$25,000 per day,per violation or administrative penalties up to$55,000 per violation per day as described in Public Resources Code Section 42962. x x Generatorl'ad I ity Representative Name(Print) Generator Facility Representative Signature Date HAULER/SHIP VIA: AMERICAN TIRE RECYCLING,LLC. 13001 NEWPORT RD. BALLICO,CA 95303 TRUCK# LIC PLATE# DECAL# TRAILER/BOX INFO: PICKUP# DELIVER# I Cerify that under penalty of perjury under the law of the state of California taht the information provlded is true and correct in addition,I am aware that falsification of this information may result in suspenson,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 429602 and may result in civil penalties up to$25,000 per day per violation or administrative penalties up to$55,000 per violation per day as described in public Resouces Code section 42962. x x — ' / 1 Drivers Name(Print) Drivers Signature Date END USE FACILITY: TPID# Deliver Date INVOICE / MANIFEST NAME: ADDRESS: CITY: PHONE: STATE:CA ZIP: 13309 B WEIGHT CERT NET WT TONS I certify that under penalty of perjury under the law of the state of Caiifornia that the information provided is true and correct.In addition,I am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$55,000 per violation per day as described in Public Resources Code Sectlon 42962. x x End Use Facility Representative Name(Print) End Use Facility Representative's Signature Date +c pat,-T 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 0' 0 confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 et,seq,should any member of the public request disclosure ofthis infromation,I request thatCalRecyde contact me atthe address and telephone number above. Electronic,Reporting to CalRe[yCle: American Tire Recycling,LLC has been authorized by Cal Recycle to participate in the Waste and Used Tire Manifest EDT electronic reporting program.On behalf ofthe customer listed on this form,American Tire Recycling.LLC.will electronically transmit to CalRecycle ail required information from this manifest form.