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,h <br /> BY-PRODUCTI as SCRAP TIRE COMP* <br /> P.O. BOX 1 / 1300 NEWPORT RD. A NVOIC E <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314- 12/07/2006 EDT MANIFEST#: 1003314- 00045098 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT#: ADVTRA BILL TO: TERMS: NETO <br /> ADVANCED TRAILER ADVANCED TRAILER <br /> 2101 E. CHARTER WAY 2101 E. CHARTER WAY <br /> STOCKTON, CA 95205 STOCKTON, CA 95205 , <br /> TPID# 1066457-01 j <br /> I <br /> HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA <br /> TRUCK#: G /; LIC PLATE#: DECAL#: <br /> HAULER EXEMPTION: <br /> GOVT ❑ LEA EXEMPT F—] COMMON CARRIER F AG ❑ UNREGISTERED HAULER <br /> L/,( 4� _ SPECIAL INSTRUCTIONS: <br /> TRAILER: PU DEL <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> 28' TRAILER SERVICE 1.0000 EA 1,160.00 1,160.00 <br /> FUEL SURCHARGE-TRAILER 1.0000 LOAD 40.00 40.00 <br /> 111_/(q l r l- , <br /> ro <br /> TOTAL <br /> PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENT! <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 civil penalties up to$25.000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962 <br /> X X � <br /> Facility Re e e tt e sarae Print) FaciliVRepresentative's Signature Date <br /> VICHARGE ;� PAID CK# <br /> WEIGHT CERT NET WT 1.00 TONS; <br /> I certify that under penalty of perjury under the laws of the Slate of California that the information provided above is true and correct. In addition,I am aware that falsification of this information <br /> may result i uspension,revocation.or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resourcos Code section 42960 and may result in civil penalties up to <br /> $25.000 per d' per wJetion of administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962.. <br /> DrI419 a e(Print) Driver's Signature t j K7 r i s rf L Lfl r Date <br /> ' f, c <br /> a licable to all parties listed on above The information rove n rt rt 1 II of this form should be considered <br /> Confidentiality Claim ( PP P ) P �1+ . <br /> confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.seq,should a y @r df f�ublic request disclosure <br /> of this information,I request that CIWMB contact me at the address and telephone number above. <br /> � N <br /> Electronic Reporting to CIWMB: Golden By-Products has been authorized by CIWMB to participate in the Waste and Used Tire Manifest EDT <br /> • electronic reporting program. On behalf of the customer listed on this form,Golden By-Products will electronically transmit to CIWMB all required <br /> information from this manifest form. <br /> Customer <br />