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GGLMEN BY-PRODUC ') dba SCRAP TIRE COM NY P.O. BOX 1 / 13000 NEWPORT RD. INVOICE BALLICO, CA 95303 (209) 668-4855 EDT TRIP LOG#: 1003314- 08/02/2011 EDT MANIFEST#: 1003314- 00077174 DATE DRIVERS INIT RUN# SHIP TO: ACCT#: ALCO BILL TO: TERMS: NET30 ALCO IRON & METAL ALCO IRON & METAL 2201 W. WASHINGTON SUITE 21 620 PORT ROAD#22 STOCKTON, CA 95203 STOCKTON, CA 95203 TPID # 1411385-01 PHONE: 0 - PHONE: (209) 939-9310 HAULER/SHIP VIA: GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA TRUCK#: G L' + LIC PLATE#: r / r i DECAL#: HAULER EXEMPTION: GOVT s LEA EXEMPT COMMON CARRIER UNREGISTERED HAULER DEL ; �;.� SPECIAL INSTRUCTIONS: TRAILER: 2, TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT 28' TRAILER SERVICE-66 CUBIC YARDS 1.0000 EA 650.00 650.00 PLEASE PAY FROM THIS INVOICE - NO OTHER INVOICES WILL BE SENT! Invoices over 30 days are subject to a late fee of 1 1/2% per month, which is 18% annually, Or a minimum of$1.00 per month. TOTAL 650.00 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 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. Facility Representative's Name(Print) Facility Representative's Signature Date CHARGE PAID CK# WEIGHT CERT NET WT 1.00 TONS 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 may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to $25,000 per day per violation or administrative penalties up to$5,0007r violation per day as described in Public Resources Code section 42962. X1JI&V ,��' / I1',P 1 ! l ,� i / Driver's"N�(Printf Driver's Signature Date Confidentiality Claim (applicable to all parties listed on above): The information provided in Part I,Part II,and Part III of this form should be considered r c DatQ confidential,proprietary,and/or trade secret. In accordance with Title 14,CCR,Section 17041 et.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. v a w = Electronic Reporting to CIWMB: Golden 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 listed on this form,Golden By-Products will electronically transmit to CIWMB all required information from this manifest form. Customer