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ANIL <br /> _ WORK ORDER/MANIFEST <br /> O <br /> 1274877- <br /> Waste 3j-re Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center,.lnc. Name:,5U Pe,�<j+0,« , .►t� �y{tr � t C. <br /> 1407 Lone Palm Ave, Address:.2,000 "e of Vic.A e <br /> Modesto,CA 95351 . City:l .2 4 rcD 1p State::(A <br /> 209-521-6221 Zip:cPhone: <br /> TPID-1274877-01 TPID.with Sutflx:)L <br /> Load Date: _ _ , Load Type: [JVVh6le [ ]Cubic Yard [ ]Ton [ ]Pound " <br /> Decal # [,r]f�ick-up Count: <br /> t license#: state: Dot code: RWDY ]Delivery Count: <br /> 82- 2 CSA � � �Y . -- -- -- <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS , <br /> 2 • <br /> 3 <br /> 4 <br /> 'S <br /> 6 <br /> 7 <br /> 8 <br /> 9• <br /> 10 <br /> 12 <br /> 14. <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature;/&J4 bate:3-2--2.I Customer Signature: Dater-Z-/�- <br /> Drivers Name(print)([�.� ,I lj.` ' Customer Name(print) <br /> I certify that under penalty.of penury under the laws of the State of California that the Information I cerpry that under penally of peryury'under o e S too Ilf la a orma <br /> provided above is true and correct.In addition,1.am aware that falsification of this information may provided aboyeie true and collect.In additbn:l am aware Nat falsification of this.i ation mey <br /> result In'suspansion,revocation,or denial of renewal-of the Waste Tire Hauler Reto Istratbnppeurrsuant rasulbcHil panalQea up to$25,000 per da,per vblatlon or administrative penalties up to$5,0, <br /> 1ppoeer vBolalton ar <br /> administrative penalties up Wa35,o00 Per vllollatbnlP�ernday s described ntlPublday, Per vidatlon per day ae dasaibed In PudlaResource Code section 42962. <br /> Reaource'Code section 42962. . <br /> ]Imported.Load [ ]Exported Load and Location Mauler Exemption Status: <br /> Address [ ]Govemment <br /> LEAExempt. <br /> City State t [: I Agricultural <br /> Common Carrier <br />