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AMERICAN TIRE RECYCLING, LLC. INVOICE / MANIFEST <br /> Remit Payment To: <br /> 13001 NEWPORT RD. BALLICO, CA 95303 1012 11`hStreet Suite 1000 <br /> (209) 667-TIRE (8473)TPID#1904316 Modesto,,-A.95,334 8146 A <br /> PICK UP Date: <br /> DRIVERS INT RUN# <br /> GENERATOR: TPID# BILLTO: SAME AS GENERATOR <br /> NAME: <br /> NAME: ADDRESS: <br /> ADDRESS: CITY: STATE:CA ZIP: <br /> CITY: STATE:CA ZIP: PHONE: <br /> PHONE: <br /> TYPE CUBIC YARDS COUNT U/M UNITE PRICE TOTAL$AMOUNT <br /> PLEASE PAY FROM THIS INVOICE- NO OTHER INVOICES WILL BE SENT! TOTAL$ <br /> Invoices over 30 days are subject to a late fee of 1 1/2% per month, <br /> which is 18 % annually or a minimum of$1.00 per month. <br /> CHARGE PAID CK# <br /> 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,[am aware that falsification of this information may result In <br /> civil penaities 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. <br /> X X <br /> Generator Faciiity Representative Name(Print) Generator Facility Representative Signature Date <br /> HAULER 1 SHIP VIA: AMERICAN TIRE RECYCLING,LLC. 13001 NEWPORT RD. BALLICO,CA 95303 <br /> TRUCK# LIC PLATE# DECAL# <br /> TRAILER/BOX INFO: PICKUP# DELIVER# <br /> I Cerify that under penalty of perjury under the law 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 <br /> suspensor,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 <br /> violation or administrative penalties up to$55,000 per violation per day as described in public Resouces Code section 42962. <br /> X X <br /> Drivers Name(Print) Drivers Signature Date <br /> END USE FACILITY: TPID# Deliver Date INVOICE / MANIFEST <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE:CA ZIP: S 146 B <br /> PHONE: <br /> WEIGHT CERT NET WT TONS <br /> I certify that under penalty cf 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 <br /> 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. <br /> X X <br /> End Use Facility Representative Name(Print) End Use Facility Representative's Signature Date <br /> .`c nat4 Confidentiality Claim (applicable to all parties listed on above). The information provided in Part I,Part 11,and Part III ofthlsform should be considered <br /> 0o rnd confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> "� ifma °lt� of this infromation,I request that Cal Recycle contact me at the address and telephone number above. <br /> Electronic,Reporting to CalRe[yCle: American Tire Recycling,LLC has been authorized by CalRecycle to participate in the Waste and Used Tire Manifest EDT <br /> electronic reporting program.On behalf cfthe customer listed on this form,American Tire Recycling.LLC,will electronically transmit to Cal Recycle all required <br /> information from this manifest form. <br />