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Aug 01 06 02: 44p lauri 2095995655 P. 3 <br /> GOLDEN BY-PRODLOYS WASTE & USED TIRAI%ANIFEST/RECEIPT <br /> I'R11' 1.00 if: 1003314- <br /> EDT MANIFEST'#: 1003314-0 ! . . -A <br /> DATE I)RV INTL RLIN <br /> Part 1: Facility Information (Actual physical location of facility) <br /> Chl xk onc: PICK UP FRONI A GENEMTOR DELIVERY TO AN END USE FAC!;,I <br /> If applicablu.. Import :Export Imp/Exp Location: <br /> GOLDEN/STC ACCT-9: <br /> NAME <br /> ADDRESS: TIRE PROGRAM ID: <br /> ADDRESS: <br /> SITE SUFFIX: <br /> PHONE: <br /> — <br /> FRAILER#: PIU 17)�" .2 "V DEL <br /> Part 2: Load Information TYPE COUNT RATE DOLLARS <br /> USED TIRES Passenger <br /> V HOLE WASTE TIRES @ Inte-,,dQd Use: <br /> 1110DUCT: Truck i bU4AD <br /> Tractor <br /> WHOLETIRI:COUNT(C) Other -RECYCLI: <br /> -CI IHIC YARDS(Y) 1'.11F1, <br /> A11-16iD IN LBS(P) Trailer <br /> Wl-"I(;11'1'IN TONS TOTAL Dr5l OSA L <br /> awcxnw.xaddilicn i am';iWWe <br /> P07 Ilies up to S25=per day,per violation at admnistraiiia penalifis up to SS.000 per viotattionper day as described in Pudic RdsourcesC�desection 4201Q. <br /> Namc(Print) <br /> Facility Date <br /> Part 3: Hauler Information <br /> TRUCK#: <br /> 'N'I'M I Golden — —= — CA <br /> ADDRESS: 11.0.Box I LIC PLATTADDRESS: 13000 Nknqxut lZoad — — — — — — — <br /> cri-Y.ST /. 13allico.CA 93303 DECAL#: ' <br /> 11110NE: (209)W-4855 — —— — — — — — — <br /> LNREGISTER]")IIAIJLER <br /> I JAI jl,I'R I-'XI:M PTION: GOVT AG Exr-MI11, 71COMMON( 7RRMR� <br /> DRiVER'S <br /> I Certify that under penally Cf Perjury under the Lawn of the State of California thal the eftmation provided above is true and carrecL In addhirin <br /> pPraim.trevoCation.or denial Tire Hauler Registration pursuant t0PubhCRe5ourczs Code section 42980 and may rest..I am avAm that WMlicatian,of thm inrcrrn�ily=may result n sus- <br /> ,rat,POW1111P.1 up 10 S5,000 per violation per day as described in Public Resources Code section 42962 lit in Civil penalties up to$25,000 per dap.per violation or admi nrs- <br /> 5n is Nurric(I'lild) Drivur-s Signalturc Dalc <br /> Part 4: Other Infonnation(Golden Bv-Products in-house use only) <br /> 1,00#-. 1, F7- <br /> - - — — — — — — — WEIGHT CERT'#: NET WT: TONS <br /> For the otbr half ofthis tran%actinn.hauler is also thc: .`Gencrator End use facilitv <br /> MANIM'STil: M <br /> — — — ———— —— — ——— ————— — — — — ———— ———- - - <br /> (ioitkn's attar halt of tnnw3i++n <br /> ft 41tlir I:IYI'Ilaid,:r I-'.D = <br /> I'Mi&q# !'aperlvlanifcst#in pla.-,-,ol'GA&-wis EMI'ManitL-i 0 f4w. (cjrvk-enc) lli'k.iq! <br /> %c D an I D11,, Confidenfixility Claim(applicable to all parties listed an above):The information prDvitied in Part 1,Part 11 and Part III of this form should be considered confi­- <br /> dential,proprietary,and/or trade secret.in accordance with Title 14,CCR,Section 17,941 et.5".should arty member of the public request disciosue of this <br /> information,I request(hat CnNW contact rm at the address and telephone number Eillove. <br /> Electronic kciportins itoerwhis:Golden By-Products has been authoruw by CM&L3 10 parbupaie in the Waiste and Used The Manile,%! 1"cuonic <br /> repo"program.On behalf of the customer listed on this form Gowen BY-Products will electronically transmit to CIVVMB all required informzt' rem this <br /> manifest form. j <br />