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JUL-06-2004 04 :21 PM MATAGA OF STOCKTON 209 3206530 P. 05 GOLDEN BY PRODU TS WA`STF & USED TIRE 1VAMFEST/RECEIPT EDT TRIP LOG %'- J - C , - M. T MANIFEST#: 1003314-0 U U 9 510 -A DATE — DRV INTL RUN fi INVOICE ft rt6i�' - Part 1: Facility Info r Cation (Actual physical location of facility) Check one: I PICK UP FROM A GENERATOR 1-1 DELIVERY TO AN END USE FACILITY If applicable: FlImport UExport Imp/Exp Location: NAME: � .G+ '' G► !'. t'/�a, GOLDEN/STC ACCT#: ADDRESS.- ,r> ADDRESS: �� !rr'- c r �, 1 ('IRE PROGRAM ID: CITY,ST,ZIP:,S'4- 'Ft�t�, SITE SUFFIX: PI[ONE: '�` `.-. :`/' 9�:i/r'- — — TIWLER H: P/11 Part 2: Load information TYPE COUNT RATE DOLLARS '.;USED TIRES Passenger '/ @ .® P'' Intended Use: tl WHOLE WASTE TIRIES Truck - JPRODUCT: @ Tractor FiRETREAD e WIIOLE TIRE COUNT(C) @�= 4RECYCLE 'DCUBIC YARDS Y Other �@ iNUEL WIIGIIT IN[.BS(P) Trailer @ = -:e[ i IDISPOSAL uWEIG1Fr IN TONS(T) TOTAL /"Z � I cenify that under penalty of perjury under the laws of the State of Calirurnia Ilial the,information provided above is true and correct In addrtion,t arri aware that falsification of this intornabDri may result n civil Penalties up to$25,000 per day,par violation or administrative penalties up to$5,000 per violation per day as desuilied in Public Resouirps Code section 42962. a- Facility Representative's Name(Pring Fadilitykepresentative's Signature Date Part 3: I lauler Information TRUCK#: / .9�,'*`STATF: CA NAME: Golden By-Products,Inc. ADDRESS: P.O.Box 1 PO# w �•--�J LTC PLATT-#: ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 0 PIPONE: (209)668A855 OsGGt� DECAL: ' ❑UNREGIST•ERED HAULER HAULEREXEMPTTON: UGOVT !! AG _at0A : CARRIERJ, ; DRIVER'S LIC#: I certify that under penally of perjury under the laws of the Slate of California ry7r ion provided above is true and correct.In ad 0i r(S yl aware that falsihcation of this information may result in sus- pensinrr,revocation,or denial of renewal of the Waste Tire Hauler Regisua rsuant to Pudic Rasgtnes Cude ser:arn 4G9ti0 and m r rn quit penalties up to$25.000 per da.per violalioy0r adminis- trative penalties up to$5,000 r violet I"per day as described in Public Resources Code secuon 42962. / Driver's Name(Print) y— --- Driver's Si turf. ^— Dale r Part 4: Other Information(Golden Bv-Products in-house use or►ly�. LOG#:L - WEIGHT CERT#: NE'I WT: TONS For the other half of this transaction,hauler is also the: L,Generator L'End use facility MANIFEST#: M - -R tiuldclt's other half of transactionµ 'Other EDI'hauler bUl Manifest If 11'aper Manifest fi in place of Guldens PDT Manifest 4 tor: (circle one) Pick-up Delivery ,c Varp Confidentiality Claim(applicable,to all parties listed on above):The information provided in Part I,Pan It and Pan Ili of this form should be considered conft- �04 Grp dentias,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 atseq,should any member of the public request disclosure of this 7a inhii matiun,I request that CIWMB cuinlacl me at the address and telephone number above. � - m Electronic Reporting to CN MB:Golden By-Products has Dean authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program.On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required information from this manifest form. 1101091#