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1 <br /> e - <br /> ® '_ WORK ORDER/MANIFEST <br /> 1274877 .961 . <br /> Waste Tore Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center,Inc. Name:SJ?#_, S+u✓e. ►^iries'`WY St��� <br /> 1407 Lone Palm Ave. Address:2 Ow <br /> Modesto,CA 95351 City: L&41 fop State: fel <br /> 209-521-6221 Zip:1 4 Phone: <br /> TPID-1274877-01 TPID with Suffix: p( <br /> Load Date:l I Load Type: [y"Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # t - r [APick-up Count: <br /> License#:S- ,.y Z,C.y L> StaDot coder RWDY [ ]Delivery Count:_ _ <br /> SIZEMFG. DOT# TREAD WHEEL COMMENTS <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 /> 17 <br /> 18 <br /> 19 r <br /> 201 <br /> Qrivers Signature:(I 111f Date: _-6-If CustomerSignature: Ar Date:'/- ' <br /> Drivers Name(print),E,�, .ltpf:l L.. fu`ff`` Customer.Nartie(print) <br /> lcenify.that under penalty of perjury under the laws of the State of California that the Information. 1 certify that under penalty of perjury under" aws of a tate of(2d;?" <br /> a iti the Information - <br /> provided sbwe a true end cartect.in addition,I am aware that falsfiratbn of this Information may provided above is true end correct.Imaddition,I am aware that fatsiflca notthis irdonnetlon may <br /> + -result In suepenslon;revocation,or denial of renewal of tha Waste 71re.Hauler Registre0on pursuant result civil penalties up to525,000 per day;pe[yiolaflon or adminlatretive pernaltes up to$5,000 <br /> to th Publio Resource Codesectbn 42960 end may result in civil penalties up.to 525,000 par day, per violatlpn Der day..scribed m Pda'Resoolat Coda seCllon 42962.; <br /> _ pet violation or administrative perefuse up to 55,000 per violation per day as desc[ibed in Fubllc t - <br /> Resource Code section 42962. - <br /> [']Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Ot <br /> Address [ ]Government <br /> [ ]AS <br /> LEA Exempt <br /> State [ ]Agricultural <br /> City <br /> ]Common Carrier <br />