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Plug 01 06 02: 46p lauri 2095995655 p. 6 <br /> • GOLDEN BY PRODUAS WASTE & USED TIREONIFEST/RECEIPT <br /> i,i),r TRIP LOG#: 1003314- '' %`_ l';'_- - '�� ` - -� EFT MANIFEST#: 1003314-0 - -A <br /> IWO DRV IN-11" RIJN# I\�;OtCE <br /> Part 1: facility Information (Actual physical location of facility) <br /> Chock one: ,i PICK UP FROM A GENERATOR DELIVERY TO AN END USE FACII,I I'Y <br /> If applicable: Import t Export Imp/Exp Location: <br /> }. GOLDEWSTC ACCT#: + ! <br /> NAME: <br /> ADDRESS: .') '!, ,ri jy 3fle ?,-r i� <br /> TIRE PROGRAM ID: .i <br /> ADDRESS: — — — <br /> CITY.S"1', 'LIP: - SITE SUFFIX: 0 11 <br /> J TRAILER k P/U 53L} i <br /> Part 2: load Information TYPE COUNT BATE DOLLARS <br /> . USEDTIRES Passenger = <br /> X,% IOI,I WASTE TIRFS g _ intct3tlecl Use: <br /> Truck @� - RE TREAD <br /> Tractor @ _ _ LI;CYCL1i <br /> WHOI"1;TIRE COUNT(C) ISE,' 45ibe <br /> Other �' � — — u1'�' ` <br /> @ <br /> C1 JBIC YARDS(Y) <br /> WEIGHT IN 1:135(P) Trailer INSVOSAL <br /> `XWEIGHT IN'TONS(T) TOTAL . <br /> I Cindy that under penalty of pertury under the kavis of the,Slate of Caklamka That the LiVornmalmn provided above is true sr_,correct.In addition,I am avarethal falsification d this inicrmAion nt3y rosult in evil <br /> penalliees up to 325.000 per day.per violatian or administrative penalties up to 55,0D0 per violation per day as described in Public Resources Code section 42962. Flf1 <br /> Pauilih Ite(tn.etirarirc'sName(Pnnq Paeitit�_Rrprvsit«hve'sSipaturu <br /> Part 3: llaulcr Information TRUCK#: L{J STATE CA <br /> NAME: Goidun Bv-Pr<xlucts.Inc. -- <br /> ADDRI;SS. N.O.Box ! LIC PLATE <br /> ADDRENS: 13000 Nc%vpo t Road <br /> crrY.S•r.zw: Ra(licti,CA 95303 <br /> DECAL#: <br /> PIIONh: (209)668-4855 — — ' — -- — — — <br /> �UNREGIS'I'l;R.ED IIAULT, R <br /> I1AI II.FR 1=XIiMP"rlON (1(rir'r A(; 1 F:11-"X1iMYT DRIVER'S LIC Ii`: <br /> t cendy mal under penalty of perury under the taws or the state of Carfomia that One w4ortrwhon provided above m true and coned.In addition.I am aware that falatTilalion of this inform-A=nuy me ft in sus- <br /> pension.revocation,or dermal of rerwral of ere Waste Tie Hauler Registration purwarn to Public Resources Code section 42OW and may result in civil penalties up to 525.000 per dry,per vi3l_-licn w adminis- <br /> trative penalties up to 35,00 per violation per day as described in Public Resources Code:action 42962. f� C <br /> It <br /> Driticr'.Name(Print) Drivel's signature Oarc <br /> Part 4 Other Information(Golden Bir-Ptvducts in-house use only) <br /> 1.06#. !.- - WEIGHT CERT#: NET WT: :0NS <br /> For the other half of this transaction-hauler is also the: IGcncrator _End use facility <br /> NIANII'I:ST'h:N-1 -li <br /> (;uldcn.Ater hall'of frtn mien 11 hitter I:D'r 1baler 1:1)1 ltsnifaa S Paper%11wdFesr N in plt cof Gardeos EDT Mani&sr>: for (urcluorc) trick-rel, Itditcn <br /> t Do/ <br /> Can Claim <br /> p v dY (applicable t0 all parties listed on above):The information provided in Pari t,Part II and Part til of this farm should Ee considered confi- <br /> dential,proprietary,and/or trade secret.In accordance•.vith Tille 14,CCR,Section 11041 at seq,should any member of the public request disclosure of this <br /> o a information,I request that CIWMB contact me at the address and telephone number above. <br /> Electronic Reporting to C1WM8:Golden ft-Products has been authorized by CMd06 to participate in the Waste and Used Tits Manifest EDT ciecttnnic <br /> •a reporting program.On behalf of the customer listed on this form,Golden By-Product?vN0 electronically transmit to CIV1+MB all required informstr-n from this <br /> rnardest form. <br />