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d 0 <br /> WORK ORDER/MANIFEST <br /> 1274877- 4,399.4' <br /> Waste Tire Ha ll r Waste Tire Generator <br /> McCoyTruck Tire Service Center, Inc. NameS'pty S4*--e5 <br /> 1407 Lone Palm Ave. Address:Zt160 LQvc'« Ale <br /> Modesto,CA 95351 City: L.4rh^t dr c', State: C ra <br /> 209-521-6221 Zip:dJfi330 Phone: <br /> TPID-1274877-01 TPID with Suffix:/Zilz "347--() <br /> Load Date: 2 -t I)-17 Load Type: [„] Vhole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # 2 - -Y' F [,]Pick-up Count: . <br /> License# r 2 0140 1 State:C4 Dot Code: RWDY [ ]Delivery Count:_ <br /> _ SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1' y 'l� �- <br /> 2 <br /> i' 3 <br /> 4` <br /> -6 • <br /> 7 <br /> 8 <br /> 9 a <br /> 10 j <br /> 11 ; <br /> 12 <br /> 13 <br /> "14 .' <br /> 1b <br /> 16 — <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature: Date:Z-°Q-#Z Customer$ignature: Date 10.,"2 <br /> Drivers Name,(pdn4) e j (, ; f /NYY- Customer Name.(print) <br /> 7r �a'Ulkl <br /> �. I�certify that under penalty of perjury,nd=,law3 of the State of California that the Information I certify that under penalty of perjury under tat of iiomla n orfne on <br /> provided above is true.ety corCect.1.addition,I em aware that falsification of this information may. provided above Is tru6 and correct.In addition.I am aware that falsification of this information may <br /> resuRln suspension,revocation,or denlal.of renewal of the Waste Tire Hauler Re�i"mtbnpursuant. !gull civil penalties up to$25.000 FFaru per violation or edministretive peneMas up to$5,000 <br /> to the Public Resource Code section 42960 andmayresult in civil penalties up to 25,000 par day; 'per'Jiolatlon perday as deacdtteQ In Public asau[ce Code'secdon 42A6'2: _ <br /> violation or adndnlstra03e penaales up to$5,000 per violation per day as described in <br /> Public <br /> p <br /> Resource Code.se <br /> clbn 42962, - <br /> [ ]imported Load :[ ]'Exported Load and Location Hauler ExemptiowStatus. <br /> Address: [. ]Government. <br /> 6N <br /> [ ],LEA Exempt <br /> City State j ]Agricultural <br /> [ jCommon Carver <br />