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Aug 01 OG 02: 45p Lauri 2095995655 p. 5 GOLDEN BY PRODS WASTE & USED TIRIACNIFESPRE CEIPT i F.DT TR[P LOG #: 1003314- - `/ - _ f _ _ _ `�`'�_ - F;DT MANIFEST#: 1003314–0 -A DA rt:, DRV INn RUN# !1NOIC'l # Part 1: Facility Information (_Actual physical location of facility) Check one: "PICK UP FROM A GENERATOR H DELIVERY TO AN END USE FACII=ITY If applicable: Amport ;Export Imp/Esp Location: GOLDEN/STC ACCT#: t` L ADDRESS: ADDRESS- TIRE PROGRAM ID: ;1 .. - _ r� � � -- -- - CITY. ST,ZIP: STIE SUFFIX: PHONE: — — y TRAILER#: P/[J DE,1 Part 2: Load Information TYPE COUNT RATE DOLLARS IJSI;D TIRI:S Passenger i Gr ....W1101.11....W1101.11'WASTI TIRES —may @ – Intended IJsc: PRODUCT- Truck C- _ — Tractor @ _ to��ItI-AU Wl-IOLI;THU,COUNT(C) – RI CYCLE CllI31C YARDS(Y) Othef '`' Sts y '%tri< @ WEIGHT IN I.I3S(P) Trailer 'P 1?f�,, .OSAL WEIGHT IN•roNS(T) TOTAL I tMbfy that trioer pmtaiiy of perjury under the laws M ono State of t:atdomwIFat the"to providedabove nue trand co rrect,in addition,1 atrf aware Viet 18134 radon of this rnr0:n:alon:nay result n cr+:l penalties up 10$25,(100 pet day,_pzr violation or admnistratiue penahias up to ss coo per violation per day es di;scribad in Public Resources Code tectiort 42952. F:tciliti'Rcitn u nr tti�c Natrk(Print) Facility Rcpxscnta e's 3i;natun r)rt` _— Part 3: Hauler Infbnnation CAi a t ' A NAMIi: (iotdtxi TRUCK f S. I3�-Products,Inc. — — ` ADDRESS: P.O.Box I LIC PLATE#: ADDR12SS: 13000 NcivTort Road — CITY.ST.%IP_: `Railieo.(('A 95303 I'IlONIi (209)668-4855 DECAL#: :.. I JNREGIST RED HAULER HAt11,1?R RXIi14IP'1'[ON c;ovr Ac 1YA HxI-NIN, -k-(1tMMONCARRu:R DRIVER'S LIC#: I-ertdY that under penalty of perlury under the laws of the state of Califama ttwt the,nror mhon Provided above is true aiid,rtirrect.to addition,I am aware 0%0 tabdiration of this nfermw1on may result in sus- pension•revocation.or denial of rcriewar or am Waste Tire Ftauter Regtwatnn pursuant to Pubfic Resources Coda saetlm_42*a and may retwl�tewil penalties up to ,000 por Cay Fw wolawn or admnis- tratrvo penattie5 up 10 551oro par violation per day as desdibed n Public Resculces Code section 4290. - Ihttit is Na i['rinU - Driw s Si ratan -- - — s Part 4: Other Information(Golden 131-Products in-house use only 1.()0T#: I.— - ——— —— —— WI'IGITr CERT#: —— NET WT: For the other half of this transaction.hauler is also the: -;Generator 'lEnd use:facility ,YIANti'I3S"r#: M- - --- - - - -- -- - - --- ------- ------ - - --- -'C3 (;uldun's odor half nt irmsactitm 9 t tura 1131'f rattM-I Ayl•mmitLns iY Paper Mamh-st#in 02xc orcroldebs lwr 114anif•si i1 ti)r. (ciriJe mc) pick-ul, Ovlivcr, 9�a DafQr Conftdentiarrty Claim(applicable to ad parties listed on above):The Wortretion prorcled in Part f,Part 11 and Part 111 of this form should be consideredcoral_ `tic .p dernial,proprietary.andhr trade secret.In accordance with Title 14,CCR,Section 17041 et seq,should any member of the public requew disciosure of Ibis a information,I request that CIWMB contact me at the address and telephone number above. W " Etectronie Reporting to OWMIS:Golden By-Products has been autflorized by CI1nlAifl3 to participate in the Waste and Used Tree OAandesi ED'electrory6; reporting program.On behalf of the customer listed on this form,Golden By-Produr s vdll etecttooically trartamd to CIWMB an required information from this manifest fami. I