|
JUL-06-2004 04 : 19 PM MATAGA OF STOCKTON 209 3206530 P. 03
<br /> WASTE & PSED MRE MANIFESDRECEIPT
<br /> EDT TRIP LOG#: 1003314- /CJ— J CC - EDT MANIFEST#!: 1W3314-0 005170 - A
<br /> DATE DRV INTI. RUN R INVOICE H
<br /> Part 1:Facility�InforrMatiio�nn (Actual physical location of facility)
<br /> Check one: ;WC.K UP FROM A GENERATOR i 1 DELIVERY'TO AN END USE FACILITY
<br /> If applicable: i !import I iExport Imp/Exp Location:
<br /> NAME: 1 GOLDEN/STC ACC ;,—
<br /> ADDRESS: Vis" �,. � >' r �' TIRE PROGRAM ID:
<br /> ADDRESS: `'' C``_,.' t. . r_ — — — — — — —
<br /> CITY,ST,ZIP:..S :,r df-�''cs.� G� .,rf qj la. SITE SUFFIX:
<br /> PI[ONE: — —
<br /> TRAILER#: P/U DEL
<br /> Parr 2: Load Information TYPE COUNT RATE DOLLARS
<br /> USED TIRES Passenger c ��— �'
<br /> J*, HOLE WASTE TIRES � ��-` " '"' Intended Use:
<br /> Truck @
<br /> !PRODUCT:
<br /> Tractor I; @ i !RETREAD
<br /> IXWHOLE TIRE COUNT(C) Ogler RECYCLE
<br /> (-:CUBIC YARDS(Y) - — — �4FUE' L
<br /> L_'WLIGHT IN LITS(P) Trailer �_ _ I (DISPOSAL
<br /> !WEIGHT IN TUNS(T) TOTAL
<br /> 1 certify that under penally of perjury wryer the laws of the Stale of California that the information provided above is true and uxrecl.In addition,f am aware Thal wwlkatkn ul Ihb in(onnabon may rosuit in civil
<br /> perw up l0 525,000�per day,pexT,r,-'rlaiiun orpElrainiairative punallias up in$S,OOD par violation per day as m Publi:Resources Code s%uon 42862
<br /> f. r
<br /> �,' ,�,,,,. �',� '..."- -.-"fwd/_ .= .�.,•,_...-...r-�..
<br /> Pacility presenlati e's Name(Print) Facility lZipresentutivc's Signature Daae
<br /> Part-3: Hauler Infordnatiuu
<br /> TRUCK#: — �a%,r � STATE: CA
<br /> NAME: Golden By-Products,Inc.
<br /> ADDRESS: P.O.Box I LIC PLATE#: z/5, �y_7
<br /> ADDRESS: 13000 Newport Road
<br /> CITY,ST,Z.IP: Ballico,CA 95303 DECAL#:, rJ � – >� rP ?_3
<br /> PHONE: (209)668-4855 — — — — — — —
<br /> I IUNREGISTERED HAULER
<br /> HAULER EXEMPTION: 1.IGOVT J AO L LEA EXEMPT i (COMMON CARRIER DRIVF,R'S LIC#:
<br /> 1 certily ilia,under penally of perywy wader the laws of am State of Cahlomia that file intormauon pruvided ab va is true and c}�r�•yr.Ina don,I am aware that latsitiealim of this folormation may result in sus-
<br /> pension,revuuallon,or denial of rsoo al or tim Wavle Tire Hauler Ray(niraka,pwsurnf to Public:Resoweess Code vection 129,00 aryl result in civil penalties up to$25,000 per day,per vio 'an or admirrs-
<br /> Native fwrwiliev up to ss 000 per violation per day as described in Public Resources Code section 42962. j ,7
<br /> Driver's Name(Print) j>rl'v s Sig1lt�Ci+re Date
<br /> r'
<br /> Part 4: Other Information(Golden By-Products in-house use onl4l
<br /> LOG#:L_ - _ _ _ _ _ _ _ WEIGHT CERT#: NET WT: TONS
<br /> :.:For the other half of this transaction, hauler is also the: DGenerator LEnd use facility
<br /> MANIFEST#:M - _ g
<br /> IGutdcu'a called lull of nausaetiuu& QWor EDT Hauler EDT Manifest N Paper Mailed M in place of Guldens EDT Maudux r< tor. (circle one) Nick-up Dofivcty
<br /> Confidentiality Claim(applicable to all parties listed on above):The information provided in Part I,Part 11 and Part 111 of this form should be considered
<br /> 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
<br /> this information,I request that CIWMB contact me at the address aro]telephone number above.
<br /> Electronic Reporting to CIWMB:Golden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic
<br /> reporrlrtg program,On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required Information from this
<br /> manifest form.
<br /> 1um't+tf:l
<br />
|