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FROM :CALAVERAS GARAGE FAX NO. :209-464-5126 nec. 23 2004 10:48AM P3 --------= �..._. ---------- - --- - ---------------------------------------------- WASTE., -WASTE & USED TIRE MAN FESURECEIPT EDT TRIP LOG#: 1003314-.3_/ /0y_-—MF__ - -1 EDT MANIFEST#: 10033,4--o . 008981 -A DATE DRV INTL RUN# LNVOLCE# Pan 1: Facility Information (Actual physical location of facility) Check one: / PICK UP FROM A GENERATOR Li DELIVERY TO AN END USE FACILITY If applicable_ L'Import LExport Imp/Exp Location: NAME: U A ILA t2 t GOLDEN/STC ACC"r#►:_ — — — — — — ADDRESS: 40 so ji ' WV `.� ST TIRE PROGRAM ID: .ADDRESS: — — — — -- — — CITY, ST,ZIP: Vr4U%TV N S ZO S SITE SUFFIX: O 1 PHONE: TRAILER#: P/U DEL Pan 2: Load Information TYPE COUNT RATE DOLLARS USED TIRES Passenger 1-10 O g ls ( A q.100 Intended Use: WHOLE WASTE TIRES Truck -L ® S4 = 11 .00 PRODUCT: QRETREAD /WHOLE TIRE COUNT(C) other- t4 t 1h S 110 @O.S U n 5�0 V RECYCLE ..CUBIC YARDS(Y) /FUEL WEIGHT IN LBS(P) Trailer.: 0 = 12DISPOSAL WEIGHT IN TONS(T) TOTAL -LN"L a 1 cerlify that under petWty of perjury under the laws of the Stare of California that the irdormmion provided abova)r uua and correct.In addition,i am aware that falsiticafon of this information may result in civil oenalnes up to£25,000 per day,per violation or adminisualive perutlliea up 10$5.000 par violation per day as 083crflied in Public Rmourcas Code section 12962. Facility Representative's Name(Print) _- Facility t2cptcsznutive's Signature uc Part 3: Hauler Information TRUCK#: — STATE: CA NAME_ Golden By-Products,Inc. ,ADDRESS: P.O.Box I LIC PLATE ADDRESS: 13000 Newport Road CITY,ST,ZIP: Ballico,CA 95303 DECAL#: PHONE: (209)668-4855 HAULER EXEMPTION: _GOVT U Ac LLEA EXEMPT COMMON CARRIER DRIVER'S[JUNREGISTERED HAULER LIC#: l Cerity[1131 under pen9ily of peri Ury vnder the laws of Ute Slale at CZ. f0nlia(hal Ina iMlOrMalien prpvided above fe true and correct.In addition.I am aware LKSt lalmilication pf tMe inlormalian may result in ;- pensnn.r vocation,or denial of renewal of tho waste Tire Hauler Registration pursuant to Publle Reeeurcps Code secflon 42960 and may result in civil penalties up 10;25.000 per day,per vid1360n 0r admfniE- t 9,ivs penalties up to 5;.07 00 per violation per day as deecribed in Puwc Resources code section 42962. [giver',;Name(Print) Driver's Signature Date Part 4: Other Information(Golden BY-Products in-house is on] 1 LOG#:L` - — _ — — — _ — WEIGHT CERT#: NET WT: TONS For the other half of this transaction, hauler is also the: L Generator f_JEnd use facility MANIFEST#:M— - - - - - - - ---- - - - - -- -- ------- - -- - - - - - - -B Goldcn's other half of transaction# ::Other EDT Haulcr EDT Manifest# iPaper Manifest*in place of Gotdens EDT Manifest u for. (circle one) Pick-up Dcli- cry Confidentiality Claim(applicable to all parties listed on above):The information provided in Part 1,Part tl and Pan III of this form Should be considered 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 C1WM6: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,Got den By-Products will electronically transmit to CIW M8 all required info rmarinn fenm fhic