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4 ' ® WORK ORDER!MANIFEST <br /> • 1274877 <br /> Waste Tire Hauler Waste Tire Generator f <br /> McCoy Truck Tire Service Center, Inc. Name:�?ca/�Q f S1 a✓ s nd '��rCK J �cC <br /> 1407 Lone Palm Ave. Address: ; Ave <br /> Modesto,CA 95351 City: �'-4:4v.Jor State:�-,4 <br /> 209-521-6221 Zip:g4 330 Phone: <br /> TP I D-1274877-01 TPI D with Suffix:l q q'�3!p$-Q <br /> Load Date:q I ? Load Type: [LA4hole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # i i - r i L [,Pick-up Count: <br /> License#:art tiry 3 Stater Dot Code: RWDY [ ]Delivery Count:_ <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1vs — 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 /> {` 14 <br /> ij 15 - — <br /> 16 <br /> t 17 — <br /> f 18 <br /> 19 -- <br /> 20 <br /> Drivers Signature: « p" Date: -/j-�1t Customer Signature: Date:9-' -t f <br /> Drivers Name(print) 14:t f.u e t i- I�ta'tr Customer Name(print) <br /> I certify that under penalty of perjury under the laws of the State of California that the Information I certify that uMer penalty of perjury untler the aws of the State of alifomla that .�ormalion <br /> provided above is true and correct.In addition,I am aware that falsification of this information may provided above is true and correct.In additbn,I am aware that falsification of Ihls in ormatlon may <br /> result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Re@istratlon pursuant result civil penalties up to$25,000 per day,per violation of administrative pdnalties up to$5,000 <br /> to the Public Resource Coda section 42960 and may result In civil penalties up to$25,000 per day, per violation per day as described In Public Resource Code section 42962. <br /> per violation or adminlstretive penalties up to$5,000 per violation per day as described In Public <br /> Resource Code section 42962. <br /> t! <br /> [ ] Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address. [ ]Government <br /> [ ]LEA Exempt <br /> City State: f [ ]Agricultural <br /> y [ ]Common Carrier <br /> �. <br />