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lb& EN BY-PRODUCT5f a SCRAP TIRE Gptz "NIIW _ � �pZ 61 '110 auiil paniaaaa <br /> �- =3 P.O. ;J30k1 / 13000 NEWPQ.RT RIS. INVOICE <br /> BALLICO, CA 95343 "(209) 668-4855 <br /> EDT TRIP LOG-f: 1003314- 01/31/2011 AM 1 EDT MANIFEST#: 1003314- 00073588 <br /> DATE DRIVERS INIT RUN# <br /> SHIP TO: ACCT#: EVER BILL TO: TERMS: NET30 <br /> GIANT TOYOTA TOWN EVEr3GREENOIL, INC_ <br /> TOT001 DEPT. LA 23234 <br /> 2160 E HAMMER LANE PASADENA, CA 91185-3234 <br /> STOCKTON, CA 96210 <br /> TPID# 1026679-01 <br /> PHONE: 0 - PHONE: (510) 608-0159 <br /> HAULER/SHIP VIA: Gni DEN BY-PRODUCTS 13000 NEWPgRT RD. BALLICO STATE CA <br /> TRUCK#: GEP087 LIC P�tTE#: 8A41898 DECAL#: 11-04378 <br /> HAULER EXEMPTION: FIGOVT_ D LEA EXEMPT COMMON CA IER UNREGISTERED HAULER <br /> SPECIA INSTRUCTIONS: <br /> TRAILER: PU DEL <br /> TYPE COUNT IU/M UNIT PRICE EXTENnFD AMOUNT <br /> PASSENGER TIRE IEA <br /> It <br /> I <br /> i <br /> I <br /> PLEASE PAY FROM THIS INVOICE-NO OTHER INVOICES WILL BE�ENTI <br /> Invoices over 30 days are subject to a late fee of 1 112% per month, TOTAL <br /> which is 18% annually, or a minirnuin of$1.00 per month. <br /> I r crtily that undor ponally of perjury under the laws of the Slate of Celifomia that the Inform4lian provided abovo is true afd corrQV1, In addition,I em avrnra gnat taislficov n of true miuo warm <br /> may rosult in civil penalties up to$25,000 per day,per violation or adminiarativo pcnaltiee up to$5,00D per vloialion per day as describod in Public RQiQyrws Code section 42962. <br /> x X <br /> Facility Reprl�entapve's Signature Date <br /> Facility Representative's Name(Print) ti <br /> 77 CHARGE PAID CK# <br /> WEIGHT GERT NET WT TO�JS <br /> I sonify that under ponally or perjury under the laws of tho stela of cailfomia that the Inlormation provided above is true ITd corn ,.dii7dditlon em award that falsgicalion of this information <br /> may rocuit in vu9ponclon,mvo� Linn.nr danial of renewal of tho Waste Tire Haular Rogistratlon pursuant to Public ResgyrAos'"Gode eeGLorr42960 and�y rgsylt iy'cmi penalties up to <br /> $25,ODD per days per violation or adminialrative Penalties up to$5,000 pot violation per day as described inPPubii�,P rougcer(od,D9e£uon,a25b <br /> XrF- lir <br /> Driver's Name(Print) Drivcr'o Sign tura Date <br /> I <br /> conlldentlallty claim (opplicable to oil porbae lietad on abovo): the informaHr.n prnvided in Part I_Part Il.and Part III of this form should be considered <br /> ,c Dato, confidential,propri®Lary,andior trada secret. In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure <br /> or this information,I request that GIWMB contact me at the address and telephone number above, <br /> v r I <br /> v' Electronic Reporting to CIWMB: uolden by-Products nas bccn ouil wi—cl�y CIWMtq to pariicipotc in tho Waste and Ueod Tiro Manifest EDT <br /> electronic reporting program. on behalf of the customer listed on this form,Golden t}y-Products will electronically transmit to CIWMB all required <br /> Information from this manifest for <br /> Customer <br />