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FROM :TRACY MATERIAL RECOVERY FAX NO. :2098323062 23 2008 10:33AM P2 <br /> GOLDEN BY-PRODUCTS dba SCRAP TIRE COIVIPANY <br /> P.O. BOX 7 / 13000 NEWPORT Rn. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> cL)T TRIP LOG#: 1003314- 04/03/2008 _,r�: Z EDT MANIFEST#: 1003314- 00055225 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT#: 28KZTM BILL TO: TERMS: NETO <br /> TRACY MATERIAL RECOVERY TRACY MATERIAL RECOVERY <br /> 30704 S MACARTHUR P,O, BOX 93 <br /> TRACY, CA 95379 TRACY, CA 95378 <br /> TPID# 1107038-01 <br /> WAULERISHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATEA <br /> TRUCK#: G LIC P[-ATE#; '%�� <br /> r , r � DECAL#; , <br /> HAULER EXEMPTION: <br /> GOVT LEA EXEMPT COMMON CARRIER AO UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER:t PU �, � DEI. <br /> TYPE COUNT _UlM UNIT PRICE EXTENDED AMOUNT <br /> 45' TRAILER SERVICE.-105 CUBIC YARDS 1.0000 EA 1,025.00 1,025.00 <br /> FUEL. SURCHARGE-TRAILER 1.0000 LOAD 40.00 40,00 <br /> .... t v <br /> TOTAL 1,065,00 <br /> PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENTI <br /> I certlfy that under penalty of poriury under the laws of the State of California that the Information provided above ie Imo and correct, in addition.Ism aware that falsification of thla Information <br /> may result In civil penallias up to$25,000 per day,per violation or administrative penalties up to$5,000 par violation pot day as deacdbed'in Public Resources Code section 42902. <br /> raeltity Representative's Name(Print) Facility Ropr6eentattve.a.SI6*Vre- Data <br /> CHARGE PAID CK#_ <br /> WEIGHT CERT NET WT 1.00 TONS <br /> 1 corny that tinder panalty of perjury under the laws of the State of Calk that tho Information provided above is true and correct in addition,I em aware that falaDlooliort of this Information <br /> may reauf!in cutponelon,revocalloR or denial of renewal of the Wasla Tiro Hauler Registration pursuant to Pubtlo Resources Coda noetlon 42080 and may result in civil penalties up to <br /> 625,000 per day par violation or administrative penaltles up to$5,00o pot vloietion per day as described in Public Resourcos Code section 42962. <br /> I <br /> Driver's Name(Print) Driver's SILMattire' Date <br /> Confidentlailty Clalm (applicable to all parties listed on above): The information provided In Part 1,Part Il,and Part III of this form should be considered <br /> P Doff Confidential,proprietary,and/or trade sacret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public requeal disclosure <br /> Cof tills information,I request that CIWMti contact me at the address and telephone numbor abovo. <br /> Electronic Reporting to CIWMB: Golden By-Products has been authorized by CNVMB to particJpate In the Waste and Used Tire Manifest EDT <br /> electronic reporting program. On behalf of the customer listed on this form,Golden ByProducta will electronically transmit to CIWMB all regolred <br /> Information from INS manifest form. <br /> Customer <br />