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FROM :TRAC`( MATERIAL RECOUERYFAX NO. :2098323062 ^. 23 2008 10:34AM P3 <br /> GOLDEN BY-PRODUCT ba SCRAP TIRE OOMPARR <br /> 14 ` N P.O. BOX 1113000 NEWPORT RD. INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EL- . TRIP LOG #' 1003314- 03/07/2008 7- 8 1 EDT MANIFEST* 1003314- 00054623 <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# 1107036-01 <br /> HAULERISHIP VIA: GOLDEN BYPRODUCTS 13000 NEWPORT RD. �BALLICO STATE CA <br /> TRUCK#: G— /01 LIC PLATE#: --1,6083J3 DECAL#: <br /> HAULER EXEMPTION: <br /> GOVT F_� LEA EXEMPT [] COMMON CARRIER F7AG UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: PU5 5 2 3 5 7 qEL <br /> TYPE _ _ COUNT U/M� 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 /> TOTAL 1,065.00 <br /> PLEASE PAY FROM THIS INVOICE- NO OTHER INVOICES WILL BE SEN FI <br /> I eeroly that under penalty of perjury under Iho laws of the State of Colifomla that the Information provided above to true end cQrre01 In addition,I am aware that falsification of this Information <br /> may robult in civii ponall'icis up to 125,000 per day,per violation or administrative ponaviss up to 56,000 perxviolation per day as described in Public Resources Coda section 42962. <br /> N <br /> Facility Representative'@ Name(Print) Facility Representative's signaturo Date <br /> CHARGE [—] PAID CK# <br /> WEIGHT CERT NET WT 1.00 TONS <br /> I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct. in addition,I am aware that falsification of this Information <br /> may result In suspension,revocation,or denial of renewal of the Waste Tire Ho0or Registration pursu4nt to P4blio Resources Code section 42060 and may result In civil ponaftias up to <br /> $26,000 per day per violation or edmintstrat}ve penalties up to 55,000 per violation per day as described in Puhli_Rasow"A Code section 4 <br /> X �OZ_rAN c , 8E�Y45�--- X x::, -- C / /- <br /> Driver's Name(Print) Drlver'a Signature Date <br /> Confidentiality Claim (applicable to all parties listed on above): The Information provided in Part I,Part 11.and Part III of this form should be conaldered <br /> 1101019 P confidential,proprietary,ancilor trade secret. In accordance with Title 14,CCR,$,action 17041 at.seq,should any member of the public roquest dladosura <br /> of this Information,I request that CIWMB contact me at the address and telephone number above. <br /> Electron Ic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to pefticipate In the Waste and Used Tire Manlfesl EDT <br /> electronic reporting program. On behalf of the customer listed on this form,Golden ByProducle will oloctronically transmit to CIWMB all required <br /> Information from this manifest form. <br /> Customer <br />