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4ow ® O <br /> 0 WORK ORDER/MANIFEST <br /> j 1274877- 43640 <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name:-5vQe I;,-f 6Iz ets -rN0,10lr-;�5 f lfey <br /> �cs . <br /> a <br /> 1407 Lone Palm Ave. Address: �jjID Lb C%J L <br /> Modesto,CA 95351 City:1„e{"ihr/0P State:C <br /> 209-521-6221 Zip: ^ Phone: <br /> TPID-1274877-01 TPID wiJitth Suffix: <br /> Load Date: - Load Type:-t6hole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> C � <br /> Decal # '1 7- - 0 P S ! J ick-up Count: <br /> License#: 0 State: CIV Dot Code: RWDY [ ]Delivery Count:__ <br /> ! SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 E <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 /> f — <br /> 14 <br /> E . 15 <br /> f• 16 <br /> I 17 — - <br /> 18 _ <br /> 19 <br /> 20 . ! <br /> ! /p <br /> 71 , <br /> Drivers Signature ate:!!b-) Customer Signature: Date: i1 <br /> Drivers Name(print Customer Name.(print) { t <br /> 'I certify that under penalty of p6qury Oder the laws of the Stat of California that the Information I certify that under penalty of perjury under the Jews of the Stte of Gelifomla'• et the-Fri ailation <br /> Ci provided above is true and correct.In addition,I am aware that falsification of this Information may provided above Is true and correct In addition.I am aware that falsification of this.lnformatlon.may . <br /> 1 resutt In suspension,revocation,or denial of renewal of the Waste Tlfe Hauler R j;lrallon pursuant result c1,,,penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 <br /> L[{ to the Public Resource Code section 42960 and may result in civil an it. <br /> up t$25,000 per day,. per violation per day as described in Public Resdurba Code section 42962._ <br /> C`. erAolat on or administrative penalties up to$5,000 per violation per day as described In Public - <br /> �.; ;Resource Code section 42962. - - <br /> [ ] Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ ]Government <br /> LEA Exempt <br /> CityState: [ ]Agricultural <br /> [ ]Common Carrier <br />