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FROM LAWRENCE—TIRE ' 0.N FAX 2098383538 May. Ol�vjt ] Flirt•FAX NO. 0 -I t ; ,V ��' .E� �nI�riif��,()�YlL•�f�.. �;$�f��^l � 1..1t'�..� WASTE & USED TARE MANIFEST/RECENT 0 s 2004 EDT TRIP LOG#: 1003314- l/�J l �F ..1. - EDT MANIFEST#: 1003314 _ -;Rp//lhi c -A UATF: DRV INTL RUN# INVOICE# Part 1: I~acil. .ty Lnformation (Actual physical location of facility) Check one: N PICK UP FROM A GENERATOR 0 DELIVERY TO AN END USE.FACILITY If applicable: 01mport LlExport Imp/Exp Location: ,! GOLDEN/STC ACCT#:_ J�t`_�Ln.- NAME: J•c L.' K I V C t.;rte — AT)nRFSS: I 1 i G , t1 J� kfC•,y f /a✓� TIRE PROGRAM ID: ADDRESS= ✓j —G' — — — — CITY,ST,ZIF: SITU SUFFIX PHONE' TRAILER#:.PRr�� & 'DRL5-r.2 Part 2: Load information TYPE COUNT . RATE DOLLARS LI USED TIRES Passenger Intended Use: NWHOLE WASTE TIRES Truck LiPRODUCI`. Tractor (� = ORETRE AD 1-1WHOLE TIRE COUNT(C) lSl#2ECYCLE . ❑CUBIC YARDS(Y) Other : = LIWEIGhIT IN LBS(P) Trailers- —C C%�' - -��f t' `� .'DDISPOSAI. EWEIGHT IN TONS(T) TOTAL I certify that ender penalty of Penury urdgr the law-of tM t1*20 Of CSIIIG 18 that theklfOmutkn provided above is%w AndIn ad IA- are tom Ewsi6eptipn tNA information dormation may movit in p pe-nattir up to ,Bou day,per,vl Baan or admlTI up to$5,000 per violation per day as described it PubP aW a ion L 14, Facilit�.tlti (Print) Facility Rep ve s Signamro Date ., Part 3: Hauler InfoD2Lbon TRUCK'#: _ STATE: CA NAME' Golden By-Products,Inc. ADDRESS: P.O.Box 1 LIC PLATE ADDRESS: 13000 Newport Road ST,zip: Bullico,CA 95303 Ia3CAL 4:4, 1�(y PHONE: (209)6684855 OUNRECHSTERED HAULER HAULER EXEMPTION: C7GOVT 0 AG EILEA EXEMPT OCOMMONCARRIER DRIVER'S LIC#: I co RNy that under penalty pl penury under ftfov y of ft state of California that file information provided abwo is tn,a and correct.In addlttai•I am aware that falsification of this IMorin"on may result in sus- pension,revocation,or mrrlai of ivr ral d the Waste Tire Hauler"stmtion pumuart to Pubrm Reoaaoea Cak sedion 429eo and may reaoitin civil panal6m up to 8 t55 000 Par day;per violation of odminG• twiva ranaiiim tm to ss=per violation par tidy aS CIOMM In FOR 99SoW0es O006 W10n 4ZKZ. r' Ali:�ri� .:� � -:�r5 >�• /.`'C �.r:,_ � ��.?��: briVCr'3 Name(Print) J Driver's Signature Pan 4: Other Information Gold n By-ProduFtsJn-house use only) LOG#:L_ _ _ _ _ _ WEIGHT CERT#: _ NET WT. _ TONS 7—For the other half of this transaction,hauler is also the: DGenerator - ❑End use facility MANIFEST#:M j B _1Golden's outer half of trsnsac7ion A ]Other EDT Hauler EDT Manifest# ]Paper Manifest#in place of Goide,is IDT Manifest Al far (c]ml one) Pick-up Delivery Confidentiality Claim(applicable to all parties listed on above);The in provided.in Pan I,Pall if and Pani III of this form should be considered donfidential,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 information.I request that QIW MS contact me at the address and telephone number above: Electronic Reporting to.CfWMB.Golden By-Products has been authoflzed 4y CIWMB to participate in the Waste and Used Tire Manifest LDT electronic reporting program.On behalf of the customer listed on this form,Golden By-products will electronically transmit to CIWMB all required inforinatl0n from this manifest form.