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' t ® WORK ORDER/MANIFEST <br /> 4 � o <br /> 1274.877- a4►. <br /> �• Waste Tire Generator <br /> p: Waste Tire Hader -- - t. -. <br /> McCoy Truck Tire Service Center, Inc. Name: ut"k,:a 5,�✓� -� V `�S <br /> 1407 Lone Palm Ave. Address:Aiqli <br /> Modesto,CA 95351 City:j j+-ktf0 eState . . <br /> 209-521-6221 Zip:y 5 3}0 Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: L4- '��.. Load Type: WNhole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal #L2r- t G ick-up Count: <br /> License#:It.44. A 636 StateEA,: Dot Code: RWDY [ ]Delivery Count- <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> ?o�: 40 l <br /> ;2 <br /> 3 <br /> 4 . <br /> 5 <br /> 6 — <br /> 7 <br /> 8` <br /> 9 <br /> .10 <br /> 11 <br /> 12 <br /> 13 <br /> : 14 <br /> 1.5 <br /> 16 <br /> 17 <br /> 18 <br /> 19 IF <br /> - <br /> 20 <br /> Drivers Si nature Date::q�. j Customer Signature: Date. <br /> _ . . g: l. P <br /> Drivers.Name(print) hlUvip ,� Customer Name(print) ; <br /> 1 certify that under penalty of perjury undar the laws of the state of Calitomia mat the Infonnatlon I cer0ry that under penally of perjury under the laws of the Stale of CalltomI, Ida Information <br /> ,provided above is W a_erx!oortect:In edditlon,I am aware that talsifigtlon of this iofonnatlon may - provided above Is.true and coriect In addition,l am aware that faLsiffeagoninistrative�eoffatlhiis informetion may.. <br /> .to this II?ob1lc�Resoorce Code sectlode 2960 and inay urestultlt in civil penalti1`4es upatoe05i25 000 purer day t per vbla5onaper daynalties�as tl to$escrit»d i000 n Publ'pp e ounce Code seh or ction 42962; as upto 55,000 per violation or admintetrative panatties up to$5,000 per violation per day as described in Public R - <br /> Resource Code.sactbn 0.2882. <br /> [ ],Imported Load [ ]Exported Load and Location Hauler Exemption Status. <br /> Address: [„ ]Government <br /> ]'LEA Exempt <br /> rncultural <br /> City . State: [ `1A9 <br /> j. ]Commoo Carrier <br />