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GOLDEN BY-PROD,UCT#ba SCRAPI RE 9otiZ 0NFw( -_ G Boz 6l �)o aW11 P�^ 2)2� <br /> P.O'. BOX 1 / 13000 NEWPORT RD. <br /> INVOICE <br /> Ni BALLICO, CA 95303 (209) 668-4855 <br /> .. <br /> EDT TRIP LOG* 1003314- 01/20/2011 AM 1 EDT MIANIFEST#: 1003314 00073277 <br /> DATE DRIVERS INIT RUN# <br /> ACCT#: EVER SILL TO: TERMS: NET30 <br /> SNIP TO: EVERGREEN OIL, INC. <br /> GIANT TOYOTA TOWN DEPT. LA 23234 <br /> TOT001 PASADENA, CA 91185-3234 <br /> 2150 E HAMMER LANE <br /> STOCKTON, CA 95210 <br /> TPID# 1026679-01 <br /> PHONE: 0 - PHONE: (510)608-0159 <br /> STATE <br /> HAULERISHIP VIA: Gni nEN BY-PRODUCTS , 13000 NEWRORT RD. I- J 'B�LLICO CA <br /> *•� � f`� ��c_;';,,_, t�. -9-9'=643.7'8 <br /> TRUCK#; <br /> — 87 LIC PLATE#: &A44898- DECAL#: <br /> GOVT LEA EXEMPT COMMON CARRIER UNREGISTERED HAULER <br /> HAULER EXEMPTION: 0 <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: <br /> PU DEL � <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE EA <br /> PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL DE SENT! <br /> Invoices over 30 days are subject to a late fee Of 1 1/2% per month;, TOTAL <br /> wMch iS 16%annually, or a minimum of$1,00 per month <br /> I <br /> I certify that undor penally of parjury undar the law=or the State or California that the information provlaoo auuvd is v end rw«c�t. In pddnlon,1 am s,vara that(alslticalion of this inforMe > <br /> 5�ensltes up to X25,000 par day,par <br /> violation of administrative por&6e8 up to$5,000 por violation per day o+,deecr000,inrpublic Reno p(rps Code section 42862. <br /> may result in civil <br /> P <br /> X �� /�{ ,.-• \ - - Date <br /> Faeility Relpl•esentative's Signature <br /> Facility Representative's Name(Print) <br /> I <br /> F-IARGE [] PAID CK# <br /> i <br /> WEIGH I CERT NET WT TONS <br /> I rcrtify that under penalty of pvpury under the laws of tha State of Cehfornia that the information provided above is liub and corroa. Itic tddit42 0 andaware <br /> may.r�sult inlc�l1on of Penalties up oinformation <br /> otny ro= �t In Guc"ngion,,nvnr•Ftinn,or denial of ranewal of the Waste Tire Hauler Registration purvant to Public Ry traee-0odD,• i <br /> $25,000 per da per violation or edmmistrstive onaltiea up to 55,000 Por violation per say a oena weJ buc P7 c_ c5lo crI^ —_ <br /> Date <br /> Drivers Name(Print) <br /> Dryer's$I$nature <br /> Uonf rdentlallty Clairo (opplic3bla to an ps ti�fd-rrcelisted on above): The information provided In Part I,Part il,and Part III of this form Should be considered <br /> cc`c Da1Q Tr confidential,proprietary,and/or trade secret. In avvhh Title 14,CCR,Section 17041 et-sea,should any memoer of tl�e public request diacloeuro <br /> oy of this information,I request that CIWMB contact at the address and telepho�te number above. <br /> r Wena to participate in the Waste and Used Tire Manifest PDT <br /> Electronic Reporting to CIW6Af3: Golaen by-P'oducta hos Dccn�ufhor od by _I <br /> electronic reporting program. On behalf of the customer listed on this form,Goren By-Products will electronically transmit to CIWMB all required <br /> Information from this manifest form. <br /> Customer <br />