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JUL-06-2004 04 :22 PM MATAGA OF STOCKTON 209 3206530 P. 06 GOLDEN BY-PRODUCTS WASTE & USED TIRE ANIFEST/RECEIPT IDT TRIP LOG#: 1003314-Q>_T lam+?! / � -�- EDT MANIFEST#: 1,�I- 33LA,--0 U 1 U r�4 8 -A DAIT DRV INTL RUN# INVOICE# Part 1: Facility Information (Actual physical location of facility) Check one: 111 ICK U1'FROM A GENERATOR F1 DELIVERY TO AN END USE FACILITY If applicable: UItnport LJExport Imp/Exp Location: NAME: ./ Er - �,� GOLDEN/STC ACCT#: ADDRESS: ADDRESS: ✓ /` -�i 'FIRE PROGRAM ID: � Cf GAJ ' <. r t rte- — — — — — — — CITY,ST,ZIP* 7 SITE SUFFIX: PHONF: TRAILER#: P/U DEL Part 2: Load Information TYPE COUNTRAT DOLLARS LIUSED TIRES C r•L IXWHOLE WASTE TIRES Passenger @_ Intended Use: II,PRODUCr: Truck @ – l I RETREAD -- Tractor @ = kRECYCLE HOLE"I'iKL COUNT(C) Other IJCUBIC YARDS(Y) @ ---- „FUEL I-I WLIUHT IN LBS(P) Trailer @ _ �� T �'�c: I I DISPOSAL 1_1WEIGIIT IN TONS(T) TOTAL I certify t1ml axle,Penalty of pmjury ursleu the laws of Ilre State of Crdiforno that the inforrtwtion pnfrlderl above Is and ebrreet.ln admaon,t am aware 1hal ralsdlcalfon o1 this infmnation.nay roswt in chill panatelas up b 525,WU per day,per vlotaleat w adminislrapve penalties up m S5.600 per violation per day as Josr. r PuWw Rbs+xura+'x lJtfila section 42962. Fuedij Representative's Name(Print)— -- 5 r Facilit resentative's signature Date —� Omit Part 3: Hauler Information RO* TRUCK STATE: CA NAME: Golden By-Products,Inc, p►GCt ,,v i7 ADDRPSS: P.O.Box 1 ACCt t) 3 LIC PLATE#: ADDRESS: 13000 Newport Road C1TY,ST,21P: Rallico,CA 95303 ACCt# DECAL PHONE: (209)6684855 r OKe d .....-- . (UNREGISTERED HAULER HAULER EXEMPTION: UGOVT 1_: AG LJ LEA EXEMI'1' UCOMMON CARRIER; DRIVER'S LIC#: I certify that untler penalty W perjury under the laws of the Slue u1 Calllornia oral lhu infunnedml providW aouvu is boa auJ u'Or roGl.I,/n�-,'y`♦',Inm,I„afn�awar�That(a15iM1caGon of(tits information + resell in sus- pension,revocation,or Jenfal of renewal of IIK Wesle Tae Haulm Rwjisaaliun pursuant to Public ftesuurees Code section 42960 5pdinayrro}/Ij,4n civil penalties up to$25,000 per day.per v pl811on or e&/rils- trative penalties up to$5,000 per viola r ter dyyas Jesc6l W u.Public;Resewrces Code seviion 42962. Driver's Name(Print) Driver's 'grlature : — 'Dare Part 4: Other information(Golden By-Products in-house use only /r LOG#:L - WEIGHT CERT#: NET WT: TONS !_'For the other half of this transaction,hauler is also the: i-;Generator (End use facility MANIFEST#: M -g IGulduu'a utltur Imlf of uarrs:u:liwl# 'Other EDT Hauler EDI'Manifest# (Paper Manifest N in place of'Ciuldens l:l)'l Manifi:m# for: (circle one) Pick-up Delivery Deliq Confidentiality Claim(applicable to all parties listed on above):The information provided in Part t.Part 11 and Part III of this form should be considered confi- dential,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 17041 el.seq,should any member of the public request disclosure of this information.I request that CIWMB contact me at the address and telephone number above. t' Electronic Reporting to CIWMB:Gulden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT electronic reporting program.On behalf of the customer fisted on this form.Golders By-Pruducts will efeLtrunlcally transmit to CfWMB all required Information from this manifest form- I111!II41W '