Laserfiche WebLink
JUL-05-2004 04 :20 PM MATAGA OF STOCKTON 209 3205530 P. 04 <br /> WASTE & USED TIRE M NIFESTIRECEIPT <br /> , 0(3314- / / 2 <br /> EDT TRIP LOG#: � 0 A <br /> DATF MVI"_ RUN# INVCNCf# <br /> Part 1: Facility Information (Actual physical location of facility) <br /> Check one: I' ICK UP FROM A GENERATOR I-1 DELIVERY TO AN END USE FACILITY <br /> If applicable: 1 !import I (Export linp/Exp Location: <br /> NAME: %i�Jry/ r r c'f fir._ GOLDEN/STC ACCT* <br /> � � � ,... .�rte• <br /> ADDRESS: xty'' ;..1r r TIRE PROGRAM ID: <br /> ADDRESS: — <br /> CITY,S'1',GIP: �S1 ,+!' i� ['.; �:� / SITE SUFFIX: <br /> PHONE: _ - <br /> - TRAILER#: P/U <br /> Part 2: Load Information TYPE COUNT RATE DOLLARS <br /> ; IUSED TIRES II WASTE TIRES passenger � @� �' _ `j�,��4 Inte>Ided Use: <br /> JPRODUCT: - - Truck --------------@-.—_—T= r LIRETRF.An <br /> � <br /> ,I9 WI[OLE TIRE COUNT(C) Tractor - — � REC CLE <br /> ICURTC YARDS(Y) Trtherailer �� ©@—�_ , i IDISPOSA[. <br /> I..iWEIGHT IN LBS(P) <br /> I IWEIGHT IN TONS(T) TOTAL 3 V <br /> i certify Thai under penally or perlury under the taws of the state of California that m-information pl—klsd time <br /> Is tnre and rnrrftn:t.In addition,I am aware Mal falsification of this Inlofmalton may fowl in civil <br /> ties up to s2s,000 per day,per viciatbn or admrnislrauve penalties up to$5,000 per wdation per day as dascrWT1FrNuAb*wic Resources Code section 4� 'Facility Representative's Name(Print) 'Eacilil enfatiie'slgnatare Date <br /> Part 3: Hauler Information Q# TRUCK#. _ � 49-_.S_STATE: CA <br /> NAME: Golden By-Products,Inc-ADDRESS: P.O.Box I �O LIC PLATE ij: <br /> ADDRESS: 13000 Newport Road ACCt# <br /> CITY,ST,ZIP: Ballico,CA 95303 MCI[# � DECAL#: ix't{ 'ri�' <br /> PHONE: (209)668-4855 `� — _­ <br /> I ! <br /> II UNREGTS'I'ERED HAULER <br /> HAULER EXEMPTION: LJGOVT I i AG I l ❑c Aalzlex DRIVER'S LTC#: <br /> I certify trial under penalty of perjury under the laws of the State of Callfomta that the Information provided above is uuu wilt cored.In dddlliwr,l:Min aware u»I fafsification•ot;ttiis Information may result in Sus- <br /> pension,revocation,or denial of renewal of the Waste life Mauler He9stration pursuant to Public Resources Code section 42960 and may rull in civil penalties tip t0 S2'�AUO per day,Par vidolron or adminis- <br /> vaave penahles up to$5,000 For vi wr P.ride as da.*r:riued.,Public Resources Cod.seclwn 42002. ,:�e f <br /> Driver's Name(Print) Driver's.sigtit�urc � �.•�-F <br /> Pati 4: Other hiformation(Golden Ely-Products in-house use onlX.l•.-'f� <br /> LOG#:L WEIGHT CERT#: NET WT: 'IONS <br /> For the other half of this transaction,hauler is also the: L;Generator :-1End use facility <br /> MANIITST#:M - -T3 <br /> Golden s richer lw)t of Tra nsacridn fl Unher EM Hauler EDT Manifest p Waper WWiifest#in place of Goldeas LUT Manifest if for: (eircte ones Pick-up IX-Aivery <br /> Confidentiality Claim(applicable to all parties listed on above):The information provided In Part 1,Part 11 and Part III of this form should be considered <br /> confidential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 etseq,should any member of the public request disclosure of <br /> this Information,I request that CIWMB contact me at the address and 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 /> reporting program.On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB an regtdred information from this <br /> manifest form. <br /> 11062V13 <br />