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,tr.,...:. ,.:.. 90�Z °N Warn i l l0Z 6l °O aLUI J paAI aaa� <br /> DEN BY-PRODUC1ba SCRAP TIRE ;"•�l�I� <br /> P-O. BOX 1 ! 13000 NEWPORT RD. <br /> INVOICE <br /> BALLICO, CA 95303 (209) 668-4855 <br /> EDT TRIP LOG#: 1003314- 06/24/2011 FE 1 EDT t ANIFEST#; 1003314- 00076425 <br /> DATE DRIVERS INIT RUN# j <br /> SHIP TO: ACCT#: EVER BILL TP: TERMS: NET30 <br /> GIANTTOYOTA TOWN EYERUREEN OIL, INC- <br /> GIANT 2415 CAMPUS DR. STE 225 <br /> 2150 E HAMMER LANE IR^11NE, CA 92612 <br /> STOCKTON, CA 95210 <br /> TPID# 1026679-01 <br /> PHONE: 0 - PHONE: (510)608-01b9 <br /> HAULF-RISHIP VIA' GOLDEN BY-PRODUCTS 13000 NEWPORT RD. BALLICO STATE CA <br /> GBPO85 9655421 DECAL#: <br /> 11-04382 <br /> TRUCK#: LIC PLATE#: <br /> HAULER EXEMPTION: GOVT u LEA EXEMPT COMMON CARRIER Q UNREGISTERED HAULER <br /> SPECIAL INSTRUCTIONS: <br /> TRAILER: PU DEL <br /> I <br /> TYPE COUNT U/M UNIT PRICE EXTENDED AMOUNT <br /> PASSENGER TIRE Li IEA <br /> j <br /> I <br /> PLEASE PAY FROM THIS INVOICE -NO OTHER INVOICES WILL E SENT! <br /> Invoices over 30 days are subject to a late fee of 1 1/2% per month, TOTAL <br /> whlch Is 18%arlrlually, or a minimum of$1.00 per month. - <br /> I certify thal under penalty or perjury under the Jews of the State of Colifornia that the informatlon provided aDdve.i*.t.�e ana correct. to nJJi(i��,,t ant aware tho{rmumootion of{hta lniormatio� <br /> may result in civil penalties up to 525,000 per Clay,per violalim or adminiatr tive penahioY up to$5,000 per violation IPer day as desa6b6d in Public Resources Code,g6Ctloh 42962. <br /> X X F L <br /> Date <br /> Facility Representitive's Narne,(Print) <br /> Facility R�present2tive'S'Sigrielure <br /> CHARGE Q PAID CK# <br /> WEIGHT CERT NET WT TONS <br /> r, <br /> I certiry that under penalty of Perjury undor the laws of the state of California tna(trio informaticn provided aoove is tfue and correct. In addition.� ire are ihat faisloration of this Information <br /> ,nay resull in Al iaPansion.revocation,cc danial of rcnewaI of tho Wasle Tire Noul6r Registration pursuant to Public fl`esour�Code Section on ,pKd rnay result in civil penaltio,uP to <br /> $25,000 per day per vlolation or administrative panalim up to$5,000 por violation per clay as a9wr Ucd 111 Puulic R noyrZ:eyGoylc�ootion A9Ger. <br /> Driver's Name(rrint) <br /> orlver'e an tune Date <br /> confiUrnlidlity Claim (applicablo to all prtia�z listed an above), The information provided in Part I,Part II,and Part III of this form should be considered <br /> 9�narQTJ il proprietary, <br /> request thatCcontact me at the address ad re <br /> cTitle <br /> and telephonention 17041 umber above3eq should any member o;the public request aiscluswe <br /> of this nforrnatlonI <br /> u <br /> Electronic Reporting t0 CIWMB. Golden By-Produce has been authorirod by CIWMB w parlir.ipatP in the Waste and Used Tire Manifest EDT <br /> W - '1h♦ N. <br /> electronic reporting program. On behalf of the customer listed on this form,GolQen By-Products will electronically transmit to CIWMB all required <br /> information from this manifest form- <br /> Customer. <br />