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AMERICAN TIRE RECYCLING, LLC® INVOICE / MANIFEST 13041 NEWPORT RD. BALLICO,CA 95303 Remit Payment To. (209}667-TIRE (8473)TPID#1944316 1012 11t�Street Suite 1004 Modesto,CA 95354 12218 A PICKUP ve"ys_ Date: DRIVERS INT RUN# GENERATOR: TPID#. BILL T0: SAME AS GENERATOR NAME: NAME: ADDRESS: ADDRESS: CITY: STATE:CA ZIP: CITY: STATE:CA ZIP. PHONE: PHONE: . TYPE CUBICYAROS COUNT U/M UNITE PRICE TOTAL$ AMOUNT PLEASE PAY FROM THIS INVOICE NO OTHER INVOICES WILL BE SENT! T®TAL $ Invoices over 30 days are subject to a late fee of 1 1/2% per:rnonth which is 18 % annually or a minimurrl of$1.00-per month. CHARGE AAID 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 faisffication 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 doy as described in Public Resources Code Section 42962. Generator Facility Representative Name(Print) Generator Facility Representative Signature bate HAULER 1 SHIP VIA: AMERICANTIRE 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 provided is true and correct fn addition,I am aware that falsification ofthis information may result in suspenson,revocation,or denial of renewal of the WasteTire 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 . Drivers Name(Print) Drivers Signature Date 11110 I1!11�1�11!11�g 111 111 ill, I l Ing END USE FACILITY: TPID# Deliver Date INVOICE / MANIFEST NAME: ADDRESS: CITY: STATE:CA ZIP: dw PHONE: 122'2 -1 WEIGHT CERT NET WT TONS I certify that under penalty of perjury under the law of the state of Caiifomia 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 X End Use Facility Representative Name(Print) End Use Facility Representative's Signature Date ,c pato 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 r �r� 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 infromation,I request that CalRecycle contact meat the address and telephone number above. n wa 7 Electronic,Reporting to CalRecycle: American Tire Recycling,LLC has been authorized by CalRecycle to participate in the Waste and Used Tire Manifest EDT electronic reporting program.On behalf of the customer listed on this form,American Tire Recycling.LLC.will electronically transmit to CalRecycle all required Information from this manifest form.