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� N <br /> GOLDEN BY-PRODUCTS dba SCRAP TIRE CONlPAN I( <br /> P.O. BOX 1 / 13000 NEWPORT RD. <br /> BALLICO, CA 95303 (209) 668-4855 INVOICE <br /> EDT TRIP LOG#: 1003314- 03/04/2008 j'Y . -' EDT MANIFEST#: 1C."3314- 00054540 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: <br /> B& 6 TIRES ACCT#: 86TIRE BILL TO: TERMS: NETO <br /> RES <br /> T <br /> B& I <br /> 306 W. 6TH STREET B 8 B 6TH STREETTRACY, CA 95376 305 <br /> CA 95376 <br /> TPID# 1430272-01 <br /> HAULER/SHIP VIA: GOLDEN BY-PRODQCTS 13000 NEWPORT RD. BALLICO SPATE CA <br /> TRUCK#: G /( LIC'PLATE k �/ ;i / / `:'f i f DECAi-#r. _ <br /> HAULER EXEMPTION: <br /> F_JGOVT F] LEA EXEMPT COMMON CARRIER Q AG UNREGISTERED HAULER <br /> SPECIAL INSTRUCTION 6: <br /> TRAILER: PU DEL <br /> TYPE COUNT UIM UNIT ?RICE EXTENDED AMOUNT <br /> 45'TRAILER SERVICE-10S CUBIC YARDS 1.0000 EA 1,. )0.00 1,100.00 <br /> I• <br /> TOTAL1,100.00 <br /> PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE SENT! <br /> I csnify that under penally or perjury under thu lewd of the State of Callrorm,that the Information provided aMDva to true and wrraet, In addition,I em r98ro that falalflcs(ion or tnl6 information <br /> rnXy'reswt In civil Peaainat;up to 425,000 per day,Por v*4atlon or aeminivarlve perlmltios up to S6,X0 per violation per�y ad doscrib6d in Publio Rr.iourcaa Cada auction 42862. <br /> Facility Representative's Name(Printl Faapty RupresenwUve's Signature` Date <br /> D_CHARGE.11 [] PAID CK# t, I <br /> WEIGHT CERT NET WT 1.00 TONS <br /> I certify that under penPlty or pwjury a w.,tris laws citric State cr Calif",z that(no Informal provided atwo Is true and correct. In adolllon,I am a•arv'It1al talafiaallOn of this Information <br /> may result in suappnaion,revocntlon,or danlel or renewal of nw Waste fro Hewe Aoaistration pursuant to vubuc Rosourcac Coue gocl on 42980 ons i e)•raautt In alvu panaR;oa up b <br /> 'S2S,WQ par day pNr violptiDn Or admm lrWira ponelllaa up to LS ODQ e1 v' atlon t <br /> �° D wl par day as d6ccribod In Pubilc Razjoufces,.Coctd eeciion 42%2 <br /> /�•/ J fr r !J 1`Z�� � <br /> DrIvor'S Narne(Print) '' .. -•> <br /> Driver'&Signature Date <br /> Confidentiality Claim (appllcabl5 to aft parties listed On above): The+ntormatoll PMI/lded in Part I,Part n, ii Part 111 of this rorm 5hoatd t,considered <br /> 4�Dery p confidential,proprietary,andlor trade Sdcret. In accordance with Title 14.CCR,Section 17041 el.seq,should an member of the public request disclosure <br /> ° Of this information,I request that CIWMB contact me at the address and telephone number above. <br /> E Electronic Reporting to CIWMB: Golden By-products has bean authorized by CIVVMB to participate in t Io Waste and Used Tire manif <br /> electronic reporting program. On behalf of the customer listed on this rorm,Golden By-Products will electronicall'transmit to CIWMB all rt EDT <br /> Information from this manifest form. equired <br /> Customer <br />