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,fER CERTIFICAT Y that the following described comm, as weighed,measured,or counted rr,whose signature is on this certificate,v a recognized authority of accuracy, ,v by Chapter 7 (commencing with Section iz/00) of Division 5 of the California 3 9684 and Professions Code, administered by the Division of Measurement Standards of the ,iia Department of Food and Agriculture. PIN A DATE j ❑#1 Prep. Scrap Steel WEIGHMASTER �Q�C', � ❑#2 Prep.Scrap Steel .1, ❑#1 Unprep. Scrap Steel WEIGHEDAT rY - I _if(: %'.-11,; WEIGHED FOR ❑#2 Unprep. Scrap Steel /SELLER —Se5 F-1 Mixed Scrap Steel I'' UJ 't r%L ADDRESS ❑Tin DELIVERED TO /BUYER ❑Cast Iron CARRIER -tlw��tic.. ❑motors TRUCK TRAILER LIC.NO. LIC.NO. ❑Breakage DRIVER BY Other DEPUTY ❑ON ❑OFF GROSS+TARE �a IRON&METAL a/co iron & meta/ co. 2201 W.WASHINGTON/PORT ROAD 22 STOCKTON,CA 95203 209/939-9310 FAX 209/939-9311 PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENT! Invoices ove-39 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 certify that under penalty of perjury under the laws of the Stale of California that the information provided..above is true and correct—In atldition,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. r r 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 Codesection 42960 and may result in civil penalties up to $25,000 per day per violation or ministrative penalties up to$5,000 r violation per day as described in Public Resources Code section 42962. f �. DnvePsTflame(Print Driver's Signature Date Confidentiality Claim (applicable to all parties listed on above): The information provided in Part 1,Part II,and Part ill of this form should be considered rlc baro T 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. • = 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