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Aug 01 06 02: 44p lauri 2095995655 p. 2 <br /> GOLDEN BY-PROMWS WASTE & USED TIR)AANIFFEST/RECEIPT <br /> 1-11)TTRI11 LOG 4: 1003314- EDT MANIFEST#: 1003314-0 -JA <br /> t TI <br /> )A : DRV IN'ri. RUN# INVOICE 9 <br /> Part 1: Facilitiv Information (Actual physical location of facility) <br /> Check one: •`-HICK UP FROM A GENERATOR )ELIVERY TO AN END USE FACiLl'i-F <br /> If applicable: Import !-'!Export Imp/Exp Location: <br /> G01A),1`,N1/STCACC`l7P,: <br /> NAME: <br /> ' <br /> ADDRI'sS: TIRE <br /> ADDRESS: PROGRAM 11). <br /> C1 I Y.ST,ZIP: <br /> SITE SUFFIX: <br /> PI ION E: <br /> TRAILER#: P/U Dizi, <br /> Pail 2: Load Information TYPE COUNT RATE DOLLARS <br /> 11SEDTIRES <br /> -,WHoI,I,'WASTF­1`lRES Passenger Intended Else:TrUck <br /> I,RoD(j(-'I: 111,.1 KLAD <br /> WHOLE TIREC01 TNT(c) Tractor <br /> CUBIC YARDS(Y) Other <br /> w1:14CA I I IN 1.13S(e) Tra7ler <br /> WEIGHTIN TONS(T) G�L F__ _ <br /> cI;..ty t;iji:,:--It rcn::,.jy Gi";ij;v;nZlr aiz s;z4az; III=thc vl eima!;an F4QVdzj a4ar,,o is true and tuwrtta In ad"wri.iay.a--wa aw.—air.."iGn a., <br /> penaftes up to s2s,wc pet day.per violation Draoministrative penalties 4 to$5,000 pat violation per day as da-Boribmed 0%Fiullftftsourcos Catstisaotion 429bZ <br /> 'act ItN kc ri;scjtIjti-.,;'s Ntmc I Nnt) Facility Rcrrc,.tintarivi;'s Signature <br /> Dulc <br /> fart 3: Hauler Information TRUCK#: T'7' ' ATE: CA <br /> NAME: tiolilcin d,.-1-rt4uvLs.inc. <br /> ADDRESS: 11.0.Box I LIC PLATE#: <br /> ADDRESS: 13M1 Newport Rtgid — — — — — — — <br /> CITY.ST.ZIP: Ballico.CA 95303 DECAL#: <br /> 11110NE (209)668-4855 <br /> -,'R I-YEMPTION: GOVT AG LVA NOMYY REGISTIRN) HAULER <br /> IIALJI.] <br /> COMMON CARRIFR I DRIVER'S JJC#: <br /> I cendythat under penalty wperiury"ader the WAcOltete State 0FCAldomw that the wrlof"hoin provided aboirais"ale correct Inaddairt, sult'nsus- <br /> "s n` <br /> pe ton,revocation,or denial ref renevtal of the Waste Ten Hauler RegmAration,pursuant to FuW ResoLdCOS Code section 429M and troy result in ewe penalties up to S25.001)per day.r.-x v owiror,01 adrrin� <br /> t.fle penalties up to S5,000 Per vrolatton per day as des0bedin Public Resources Code section 4299$ <br /> F)n_,'a:r—,IN.—imc-I I r i i t t I r)W,,:t.7s%iie riatur; <br /> Part 4: Other Information(Golden Bv-Products in-house use only) <br /> 1.00#: !-— - —— — — ——— WFIGHTC1.111,4: NET WT: CONS <br /> For the other half of this transaction.hauler is also the: Generator I End use facilitV <br /> — — — ——————— — ——— ———— —— ——————— —— — — - <br /> ()th,-r 1:1Y N[atilt r I-IYT Manif,,.d# I*jlwr lvlanifcst 4 in platy nf(ioldlm,�I:LYT Manifin.4#fire (Lijelc cmc) <br /> clitvn <br /> Confidentiality Claim(applicable m all Parties listed on above):The information provided in Pan 1,Pan 11 and part III of this form should rQ considered confi- <br /> denual,voprietaty•and/or trade secret in accordance vath Title 14,CCR,Section I7041 et,s"•should any member of the public request disc4osjra of INS <br /> m Da information,I request U)at CIVVMB contact me at the address and telephone number above. <br /> J <br /> Mectranic Reporting to Cjj,VM6:C;c,cien by-FrodutAs teas been authorized by C VV?t..L.3 <br /> customer)fisted on this form.Golden 8y-Products electronically transmit to crwme all required inftir,nalinn* <br /> • reportiM program On behalf of lht�r 10 participate m the Waste and Used Tire Marcors,- cit onic <br /> manilest form. <br />