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s <br /> '7 <br /> d - O <br /> ' WORK ORDER I MANIFEST <br /> � O <br /> 1274877- Q3 9 <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: ,- u/f%� � � t,-'C'S/QF 51PA( 3 <br /> 1407 Lone Palm Ave. Address: 2� Ave J <br /> Modesto,CA 95351 City:"•A y.'ra State:6A <br /> 209-521-6221 Zip:C?"-530 Phone: <br /> TPID-1274877-01 TPID with Suffix:) 4. <br /> Load Date: 'u- 12 ` 4 Load Type: [*?Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # t t [.]Pick-up Count: ____ .-- <br /> License State:jA Dot Code: RWDY [ ]Delivery Count:_ <br /> _ SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 14 <br /> 2 - <br /> - I <br /> 3 <br /> 4 <br /> 5 -- <br /> 6 <br /> 7 — <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 — <br /> 16 ' <br /> 17 _ <br /> ' 18 <br /> 19 <br /> 20 . > <br /> ,�? ,Date: >fZ 'z Customer Signet .e: {,,! Date:,;-few <br /> Drivers Signature:* <br /> Drivers Name(print) Ak t;ie t i Customer Name <br /> I certify that under penalty of%,ury under the laws o1 the State of California that the informatlon` I certify that under penalty of perjury under the. 'ws of the ate of IlfomIs that the Ihfonnation ' <br /> provided above.Is true and coned.In addition,I am aware that falsification of this informallon may provided above is true and coned.In edditlon,Pam f Is that falsl}Ication dthls Intormatloginey- .. <br /> result In suspension,revocation;or denial of renewal of the Waste lire Hauler Registration pursuant result cNlI penalties up to$25;000 ooerday,per violation or administrative pere[tfes up to$5,000 <br /> to the Public Resource Code section 42950 and may result in civil penalties up to 525,000 per day, per vlolatkn per dayas descdbad fn PuMlc Resource Code section 42962: <br /> _ per violation or admin.s muve penal5es dp to$5,000 per violation per day as described,ln Fubllc <br /> Resource Code section 42962: <br /> [ ]Imported Load [ ]Exported Load and Location Hauler Exemption Status:. <br /> Address: [ .].Government <br /> [ ]LEA Exempt <br /> City State: [.]Agricultural <br /> Common Carrier <br />