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.uu / VVL <br /> NOV.05.2010 15:54 2096574854 GBP rc <br /> GOLDEN BY-PRODUI *1000 <br /> dba SCRAP TIRE COM Y <br /> P.O. BOX 1 NEWPORT RD. <br /> INV <br /> BALLICO, CA 95.303 , .(209),668-4855 '. 1: 0- <br /> EDT TRIP LOG#: 1003314- 10/22/2010 �, EDT MANIFEST.#:,1003314 00071865 <br /> DATE DRIVERS I.T. RUN <br /> SMTP TO: ACCT#: WIL-CONNELL BILL.TO: TERMS. : NET30 <br /> CONNELL TIRE CONNELLTIRE <br /> 2211 N.WILSON WAY 221 N.WILSON WAY <br /> STOCKTON; CA 95205TPID STOCKTON; CA 95205 <br /> 1199397-01 <br /> PHONE: t)- <br /> PHONE:: (209)4f6 2581 <br /> HAULERISHIP VIA: GOLDEN BY-PRODUCTS 13000.NEWPORT RD. BALLICO v STATE CA <br /> TRUCK#: G LIC PLATE#:, S�� �I DECAL#; <br /> HAULER EXEMPTION: <br /> GOVT LEA EXEMPT F]COMMON CARRIER UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS <br /> TRAILER: PU DEQ/ <br /> -TYPE COUNT U/M. UNIT PRICE EXTENDED AMOUNT <br /> 45'TRAILER SERVICE-105 CUBIC YARDS 1.pbOQ. EA 900 00. 900.00 <br /> PLEASE PAY.FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENTI <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. TOTAL 900.00 <br /> I Certify'tfu+t Under penalty of pwiu'y under the laws of the State cf Califxnia that the information provided abOVe is true er4 oorrcct.In addition,I am avarc that'fal3ifiCsliSn cdThis infCffadtl0n <br /> msy resutt in civil penalties u3 to 525,060 per day,per vitiation or adminixhative penalties up to ss,ox oer violation perday es described in Public Resource--Cude xotion 4298?: <br /> X <br /> Facility Repmwtativs's Nam®(Print) Facility Representative's Signature :.' Date <br /> CHARGE F-] PAID COEIGHT CERT ` NET WT � TONS <br /> I certity that under penally of perlul,under the laws d the State of California that lne information provided above is true and correct.'In addition.,t am awsee"it fal4ifieetion of thin inforrnauon <br /> may rti8U11 in euepa tion,Or d[nS Or(eneW81 Of the .. ire Hauler RegislratiCn pursuant to Public Resources Code section 42960 and may result in civil penskies uo to <br /> $25.000 per day �,uiC/l I n Or administraC penalties up tp.. r violaGOn frcr day as ,gibed inYPub&c rZe90ufce6 C BBGSOn 1286 <br /> �rtver^Nam PH t) <br /> D I's 31 tun v Date <br /> Confidentiality Claim (appiiratle to aN paries listcd on above): The inf0((ri f*n P*videCl in Part t,Part II.and Part tri of this form should be wnsidered <br /> ��nary omfidential,proprietary,andlor trade secret. in accomancie mtri Title 14,GG.R,Section 17o41'etseq.should any member Of the public request disclosure <br /> .°r ram of this information,I request Shst CIVVMB contact me at the zddress and telephone number aWve, <br /> •%B EI@GtrOnit3 RE)Mrtida to CIWMB: Golden By-Products has been auttlOfiZBd by CIWMB to participate 4tie Wasp and Used Tine N�rufest EDT <br /> electronic reportn9 program..On behalf of tho custome.listed On this fcrm,.Golden Ay-Products will eledroni[�Ily transn it t0 C{WMB ell require4 <br /> information from this manifest form. <br /> Original -.Office Copy <br />