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Aug 01 06 02: 44p lauri 2095995655 p. 4 GOLDEN BY-PRODL TS WASTE & USED TIRE%A NIFEST/RECEIPT L:I]T INI1NIPEST#: 1003314— A I DA'ri.,, DRV IN"ti. RIJN# INVOICE# fart 1_Facility Information (Actual nhri°sical location offacility) Check one: PICK UP FROM A GENERATOR CJ DELIVERY TO AN END USE I:ACIIATY If applicable: Import "-!E.xport Imp/Esp Location., GOLDEN/STC ACCT#. ; NAME: - _ - - - - - 1 — ADDRIiSS: ID: ADDRESS: TIRE PROGRAM CITY.ST.ZIP: SITE SUFFIX: — PHONE: —- TRAILER#: P/U Part 2: Load Information TYPE COUNT RATE DOLLARS IJSI:[l TIRES Passenger @ - WIIOLE WASTI:TIRES -Truck Intuedc;d t_Ise: .PRODUCT: �—Tractor RI-TRE-AD WHOLE TIRIi COUNT(C) Other ---�_ ':Ri iCYC.L1; C(TRIC YARDS(Y) WEIGI IT IN LI3S(P) Trailer �_. _ _ ")ISP OSAI, WIiIGIIT'W TONS(-1') TOTAL >ti I caldy that under penally of penury under the laws or the state of Catdorrue that me nfermetlon prwided above is true and corned.In addition.1 am ower•Tat falsification of this may resur in civil rMnalaos up Io 525,000 per day,per violation or administrative penalties up to$5,080 per violation per day as described in Pubic Resources Code section 429M ):aci!ih Rrnr:�.rlarit:= fro, c Y:irtf - ±s_aitr('ti;.uaa::ati c's Sig4aturc —--- — -, ; Part 3: Hauler Information TRUCK#: - 5•t'A'i'ti: CA NAME: (io!dun I3c-PtudueLS,Inc. — — ' — AI)DRESS: 11.0.Box I LIC PLATE#: ADDRESS: 1300!)Nc al t Road — -- — — — -_ crry.S'f.%1P: DzIllico.CA 9510-t DECAL#: P1lON}:: (209)568-48» I�UNREGISTERI'D HAULER I[L�r i1.I it 3 X3'1gP'r3ON: 60V!, ori ir.r:.�rx±*!rr co rn v c.A1 to DRIVER'S LIC;+: _ I certify that L del pergky of peryurj under the im"of the State of CaHomia that the inftxmation provided above is true and coned,In addition,I am aware that falsification of this inlbrm:ihon may resWt rl sus- pension,revocation,or deniri d renewal of the Waite Tire Hauler Reyatrotion pursuant to pubic Resouross Code sedion 429W and may result in civil penalties up to$29.000 per day,per vvelalicn or adminis- tralW penahies up to SS,=per violabw por day as described in Pub#c Resources Code section 42562. Drirrr s Name(Print) _ - " —� - — Dtivcr'3 Sigeatun i)atc Past 4: Other IntitrTnation(Golden 13y-Products in-house use otfly) I.()(:il: 1. - �>r�TnH•I•CT' — - -- _ - - - LI'T 4: _ NET WT- For the other half of this transaction.ha tiler is also the: Generator =End use facility NIA.1'3Fi S-i is iti f iuldcn' dlkrlralf..f tna*�c;i,a, ) otiicr Iii)r hauler 7:13T 67noihst N Paper Maaitc%t 0 is Place ofGoWpls EpT hianifist#for. (circle orw) Nick-up i)cliccic ��6 Dal p A Confidentiality Claim(applicable to all parties listed on above):The information prov,:fed in Part I,Part It and Part III of this form should tie�ronsrdered conf- �o r dentraf,proprietary,andtor trade Secret.In accordance with Title 14,CCR,Section 17(141 et.seq,should any member of the public request disclosure Of this information,I request that CIMAS contact site at the address and telephone number aLove. 0acerooie Reporting to CIWIAB:Golden By-Products has been allUVlrized by CIVW13 to participate in the Waste and Used Tire Mantles;EDT e!ectronic { • reporting program.on behalf of the customer fisted on tttis form,Golden By-Products t;B electronically transmd to CiWMB all required info:-Nation from this i manifest form