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FROM :TRACY MATERIAL RECOVERY FAX NO. :2098323062 r. 23 2008 10:34AM P4 <br /> VVL.V�IY � f 'f'RVI,JV�► 1 ,.Jif .`yVRJ'ir I lf`tG-vV1Y11"t. �- • <br /> P.Oa EgOX 1 / 13000 NtW OkT <br /> - .y. INVOICE. <br /> BALLICO, CA: 95303 (209) %08-4855 <br /> t TRIP LOG* 1003314- 11/28/2007 <br /> EDT MANIFEST#: 1003314- 000$2866 <br /> DATE DRIVERS INET RUN 8 <br /> SHIP TO: ACCT M 28K.ZTM 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 /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA <br /> TRUCK M LIC PLATE#: * <br /> •�>.sfL: )%, / DECAL#: r(,. >r' <br /> HAULER EXEMPTION: <br /> EIGOVT F—] LEA EXEMPT COMMON CARRIER AG UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: <br /> TYPE, COUNT U/M I UNIT PRICE EXTENDED AMOUNT <br /> 45' TRAILER SERVICE-105 666IC 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 SENTI <br /> I carVy that undor panalty of psqury under the laws of the Slate of Cohlornia thot thm informatinn provldad above Is true and correct. In addltlon,I am aware that felaiffcgflon of this i0boyi ion^-w <br /> may result In civil penalties up to$25,000 per day,par vipiAllon or adminletraNe penshles up to$9,000 per vlolahon per day as described In Public ResagrCo3 Codo aeolion 42902. <br /> Y � <br /> Facility Ropresontstive's Name(Print) F'acllity Representative's Signature Date <br /> 0-CHARGE PAID CK# <br /> WEIGHT CERT NET WT 1,00 TONS <br /> I certify that undor panalty of pequry under the laws of the 5lois of Callforniq that Iho Information provided above Is Ifue and corre4, in gdditton,1 am aware that falsification of this Information <br /> may result in suspenalon,invocation,or donigl of ronowal of the Waste Tire Hauler Registration pursugnt to Public Resources Code section 42980 and mqy result In civil panalvav up to <br /> $25,000 per day par violation or atlminislrelive pari Mias up Io$5,000 per violation per day as described IYPublic Resourcao Code section 42962 <br /> Driver's Name(Print) - - Driver's Signature Date <br /> Confidentiality Claim (applicable to ail parties listed on above); The information provldad In Pan I,Part u,end Pert III of thea form should be considered <br /> "c payor confldentlal,proprlmary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et-seq,should any member of the public request disclosure <br /> 'Q of this Information,(request that CIWMB contact me at the address and telephone number above. <br /> >° Electronic Raporting to CIWMB: Golden By-Products has been authorized by CIWMD to pafilcipate In the Waste and Used Tire Manifest EDT <br /> electronio reporting program. On behalf of the customer listed on this form,Goldon By-Products will olectronIcatly transmit to CIWMB all required <br /> Information from this manifest form. <br /> �.. ....�._-_Customer �.._�.�..._.�..�..�� ....�.,.�... <br />