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WORK ORDER/.MANIFEST <br /> 0 <br /> Waste Tire Hauler_ . Waste Tire Generator a :. <br /> McCoy Truck Tire Service Center,Inc. Name: V g I'At0q w#-,e.5� <br /> i <br /> 1407 Lone Palm Ave. Address:"14, / �N <br /> Modesto,CA 95351 City:e f-hr Stateieft <br /> 209-521-6221 Zip: 1.5"33 Phone: <br /> TPID-1274877-01 TPID with Suffix: 1" L4`9 5. 3 r� <br /> Load Date: - 2,0/ Load Type: hole..[.]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # - b ick-up Count: -- — -- <br /> License#: {. Stater Dot Code: RWDY [ ]Delivery Count:_ — <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> - 7 t —- � <br /> .Y. <br /> 2 <br /> 4 =—r— ---- <br /> 6 —. <br /> �' — <br /> x.� 9 <br /> 10 — — --- - --- - <br /> r 13 <br /> '14. <br /> -6 --- <br /> .<' 17 i <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature: ate^ Customer Signature: Date; <br /> Drivers.Name(priht. ]\}: Customer'Name(print) . <br /> rla <br /> 1 cer0ry that under penally of perjury unda the laws of the Stale bf Caiifarnia tltat the'inWrmation; I�certi(y Wunder penalty of perjury under aws the State.of C Ifo is th- e information <br /> provided above Is true and correct.In addition,I am aware that falsnicadon of this Information may provided above'islrue and conact.Inaddhion,I am aware that falsification of Ihis information may`. <br /> result in suspension,re0ooatlon,or'don lal of renewal of the Waste Tire Hauler ReglstratWn pursuant result aWl penalties uD to$25,000 per dayy,per vi0letion or adminWr4a iveponalties up to$5,I= <br /> to the Public Resource Code section 42960 and ma result In civil penalties uD.to 25,000 Per day,, par vi bit perdlay'1.described In Publle Resource Code seW on 42962. <br /> Vp'r.v1cla1-or adminislretive penalties up to$5,000.per violation par day as described in Public - <br /> Rescurce Code section 4.1,2. - - <br /> [ ]Imported Load [ ]Exported Load and Lavation Hauler Exemption Status: <br /> g Address. [ ]Government <br /> EA Ex6mpt <br /> City State .,.. [ ]Agricultural <br /> ' [ ]Common Carrier <br />