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Rug 01 06 02: 48p lauri 2095995655 p. 7 GOLDEN BV PRODU!kS WASTE & USED TIRE�NIFEST _._ rRECEIPT EDIA'`l'RII'LCG nr: i OQ'i i?- EDT MANIFEST C 1003314—`J DATE DRV FNTL RUN# Part L- Facility Information (Acttlai phvsical location of facility) Check enc: t PICK UP FROM A GENERATORDELIVERY TO AN END USE FAC1I.3'I'Y If applicable: Import C_Exp ort Imp/Exp Location: NAME'- GOLDEN/STC ACCT#: 1 ADDRESS: — — — _- —— -- — .AT)DRESS: TIRE PROGRAM ID: CITY,ST. "LIP: {SITE SUPIZX: —— — — — — — -- — PJ IONS: TRAILER#: P/U Part 2: Load Information TYPE COUNT RATE DOLLARS USi:D TIRES Passenger WHOL)'WASTIi TIRES 9 .—� Intended Usc: PRODOCT: Truck _ Tractor _ R►_;i'Ir1:An WFIOI,1'_"I'IRIi COUNT'(C) Other RLI,E CU IC YARDS(Y) C YC @ = I,DL WEIGIIT IN LBS(P) Trailer "'I)ISI'OSAJ• EIGHT IN TONS(1') TOTAL I Ceniry that wdef penalty of perjury under the laws of the Slate of Calsoinia Ilial pro niosmation gabled abw0 s Inse ant rarest in addition,1 arht aware penahim up to 425,000 per day,per violation or adffwrt etiva penalties up to 55,000 violation Mat faleikalion of this nforr_Zd Jn!ruy re.,uft n Civil Pe* per day as described in Public ResOwces Code motion 42982. 7' ]'aalifC RcpCc.,•rltarlt'c 4 tianlc(Print) ' rau dCR�prc calalsi�z'sSignaNrc i!t_ Part 3: hauler Information TRUCK#: S'..... CA NAME;: Goirkn B -Products.Inc. — — — — ADDRESS: P.O.Box I LIC PLATE#: ADDRESS: 13000 Nc%vpott Road CITY.S'1'_1:P: Bathe().CA 95303 DECAL#: PHONE: (209)668-4855 — — — — — — — — IL^,iJ1.ER 1 `CI;;L]I'"1'iUN c;0V� C=iUNREGIST1rRIii)IIALi3,ER LEA EXINYI' colr]MONcnRRIt:R DRIVER'S LIC At: _ i certify that under penalty of perjury under the laws of the Stale df Californiai ornia that the information pro ed above is true and r,,rfrorl In addition,1 sm awero OW fs�r tion of Wis informatics:rrey se-.,ull in sus- pension,revtieq ,ar demel of renewal of the Waste Tire Hauler Registration pursuant to PWic Resouces Code secim Q,Al)and way result in civil penalties t$l0 525,000 per&W.ocr viololixr or admu+ts- lfalw rxnalGex up to 55.00 err uiela!ion ecr day as desrritr_+d in P bfic Rescurrax Cods,sxiion 42952. ])risers Name(Print) - — - Dnxtr's Signature Daw Part 4: Other Information(Golden �Y-Products in house 11SC ol'll�} I WEIGHT CERT#: NEYWT:— —- - --- — ! —————— }NS — —— For thu atlier half of this transaction.hauler is also the: ;AGenerator i iEnd use facility MANIFEST 4:obi - --- ---- -- - -- - -- - - -------- ----- - -- - -- - Y3 C inlde;n's cftlha:r tedtol'lrnuctirm N C tact I'M]laulcr t:D"I'BlandN' est 0 - PaT Manifest#in p)aa:ref Gold=EDT Mani)exr p tor. (cirete om) Pic.-up S k+;hen f d�DatQ Confiderittatity Claim(applicable to at parties listed on above):The information provided in hart 1,Part 11 and Part III of this form should bE,considered Conf- dertial,proprietary,and/or trade secret.In accordance with Title 14,CCR,Section 1704'.et.seq,should arty member of the public requestdisc[a ?� information,I request that Cl"AS contact me at the address and telephone number gbeve p qosure o:this 4 h Et reporting a RaAQrfing to CtVVMB:soden 8y Products has been authorized by CtWME.to participate m the tNaste and Us4!d Tire Mandest Er-:7 electronic i reporting program.On bethalf of the customer listed on this form,Golden By-Produtls w^i'etectronicall transmit to Cf 4vw all required infcr•.ttM0.1 tram this nonires!form. y I x