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?7„'.''7T .... .m•�.p,•n+q.riv�lr�.i�t79.+u s*wnvv�+:a.'r�e�er,.".�A *$°�J':E , 'v�+'a"'1!"c�4r,�r.+7@ry y7r'�rn�wn,vrWr�ey-m^-a�w.s^. ----- = -- - -- GOLDEN BY-PRODUCTS WASTE & USED TIRE MANIFEST/RECEIPT EDT TRII' LOG #: 10033 14qlJ_5/0 EDT MANIFEST#: 1003314- 0 031318 1„ DATE DRV INTL RUN# INVOICE# Part 1: Facility Information (Actual physical location of facility) Check one: PICK UP FROM A GENERATOR - ❑ DELIVERY TO AN END USE FACILITY If applicable: ❑Import ❑Export Imp/Exp Location: NAME: (� t` ft# ../,,Ii GOLDEN/STC ACCT#: ADDRESS- TIRE PROGRAM ID: ADDRESS: CITY, ST,ZIP: " G'� G'c C"`. �' �`'r SITE SUFFIX: PHONE: c ? " -° TRAILER#: P/U DEL -� -'- � Part 2: Load Idohnation TYPE COUNT RATE DOLLARS ISED TIRES Passenger ,''6 @ = Intended Use: .WHOLE WASTE TIRES Truck U ❑PRODUCT: ORETTractor @ .,._ .� RECYCLE ❑WHOLE TIRE COUNT(c) Other--��i �'�d�'(�-�r•;� @ �r✓� _ `��'� f'�rt-� ,.4CUBIC YARDS.(Y) �Lfi'UEL []WEIGHT IN LBS (P) Trailer —�@ .SSta _ ❑DISPOSAL ❑WEIGHT IN TONS (T) TOTAL 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 S25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in-Public Resourc'e's Code section 42962. 74 Z IacilitF Representative's N e(Print) Facihir6sentative's Signature Date Part 3: Hauler Information TRUCK#: _/� ? STATE: CA NAME: Golden By-Products,Inc. ADDRESS: P.O.Box 1 LIC PLATE 7L7`� ADDRESS: 13000 Newport Road _ CITY,ST,ZIP: Ballico,'CA 95303DECAL#: '< /� PIIONE: (209)668-4855 — — — — — — — — — ❑UNREGISTERED HAULER HAULER EXEMPTION: ❑GOVT ❑ AG El LEA EXEMPT ❑COMMON CARRIER DRIVER'S LIC #: I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and coftee jn addition,I am aware that falsification of this information may result in sus- pension,, vocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section,42960y�(�d ay r s°ult in cienalties $25,000 per day,per violation or adminis- ative.pe ties up to$5,000 per violation per day as described in ublic Resources Code section 42962. / 1 C, / c I ri "cr's Name(Pri Drive nature . Date Part 4. Other Information(Golden Bv-Products in-house use only) LOG#: L — WEIGHT CERT#: NET WT: TONS ❑For the other half of this transaction,hauler is also the: ❑Generator ❑End use facility MANIFEST#: M — -B Ciolden's other half of transaction# ❑Other EDT Hauler EDT Manifest# ❑Paper Manifest#in place of Golden EDT Manifest# for: (circle one) Pick-up Delivery �c Datc, 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 confi- dential, 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 o ON information,I request that CIWMB contact me at the address and telephone number above. r' ' " 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 vvll electronically transmit to CIWMB all required information from this mnnifact form