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AMERICAN TIRE RECYCLING, LLC. INVOICE / MANIFEST 13001 NEWPORT RD.BALLICO,CA 95303 Remit Payment To: 1012 11th Street Suite 1000 (2'09)667-TIRE(8473)TPID#190431 fi.. Modesto,F CA 953x54 730b A PICK UP Date � I DRIVERS INT RUN# GENERATOR: TPID# I_Z_9 4 BILLTO: ' SAME AS GENERATOR { �fa��. 4� Y1 ]L a� NAME: NAME; : ADDRESS: ADDRESS, CITY: STATE:CA ZIP: CITY: -r�"L-,.UK.-1 STATE.CA ZIP: PHONE: PHONE: . TYPE CUBIC YARDS COUNT U/MUNITE 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,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 Section 42962. .`. " X Generator Facility 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# TRAILERI BOX INFO: PICK UP# DELIVER# iCerifythat tinder penalty of perjury under the faw of the state of California taht the information provided 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 penaities up to$25,000 per day per violation or administrative penaities up to$55,000 per violation per day as described in public Resouces Code section 42962. X. }( Drivers Name(Print) Drivers Signature Date END USE FACILITY:.TPID# Deliver Date INVOICE / MANIFEST NAME: ADDRESS:) CITY STATE:CA ZIP: PHONE: 7306 WEIGHT CERT NET WT TANS 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,I am aware that falsification of this information may resuEt in civif penalties up to$25,000 per day,per violation or administrative penaities up to 555,000 per violation per day as described in Public Resources Code Section 42962. X X End Use Facility Representative Name(Print) End Use Facility Representative's Signature Date Data Confidentiality Claim (applicable to all parties listed on above). The information provided in Part I,Part ll,and Part III of this form should be considered 0�� Tn� confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 et.sec should any mermber of the public request disclosure �r ofthis infromation,f request that CalRecycle contact meat the address and telephone number above. m EleCtrOrlic,Repotting tO CaIReCyde: American Tire Recycling,LLC has been authorized by CalRecycle to participate in the Waste and Used Tire Manifest EDT r electronic reporting program.On behalf of the customer listed on this form,American Tire Recycling.LLC.will electronical€y transmit to CalRecycle all required information from this manifest form.