Laserfiche WebLink
d � <br /> WORK ORDER/MANIFEST <br /> 1274877•- 4 .1 1 <br /> Waste Tire Hauler waste Tarp Generator <br /> McCoy Truck Tire Service Center,Inc. Name:�p?V1 S-' WC' �;c us v re 1 4. 'cr"e)i. <br /> 1407 Lone Palm Ave. Address: Z UC�U lr.��i4o Ae <br /> Modesto,CA 95351 City:Le,+k✓or State:e*A <br /> 209-521-6221 Zip: � 330 Phone: <br /> TPID-1274877-01 TPID with Suffldq'V,,i 34 <br /> Load Date:("22- \[ Load Type: [t4Uhole [ ]Cubic Yard' [ ]Ton [ ]Pound <br /> Decal # I I -� 6 S 9 ick-up Count: <br /> License#:FZ,, �!O State: C.4 Dot code: RWDY [ ]Delivery Count— <br /> SIZE <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> l• <br /> 1 Z-4 70 2 2-ci � _ <br /> i. — <br /> 2 <br /> � . 3 _ <br /> �• — <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 1.0 . <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 1.8 <br /> 19 <br /> 20 <br /> t � �} p t . <br /> Anvers Signature: Z/1;i. aY�'*. 1 Date. �- f' Customer:Signature: Date. - #+ <br /> Drivers Name(print) i � ( .. / Customer Naive(print) <br /> I certify that under penalty,of perjury under the laws of the State of California that the information I cettify.that urKler.penalty of perjury under th o $tale ofCali that I on <br /> provided above Is true and correct.Iri eddhlon, am aware that falsification of this Informatlan may, proyded above Is-true and coned.In addition,I em aware thatfalslflcatlon d MI- adbn may <br /> result In suspension,revoceUon,tx denial of renewal or the Waste Tire Hauler RegisUr=tni pursuant. -result dvi penalties up to$25.000 per day,perVidation or administrative penefflil up Io$5 OOD <br /> to me Public Resource Code section 42960 and may resufl in.civil penalties tip to 525,000 per day; per violation per day as described In Public Rtsourca Code sacdori 42962 <br /> per vitiation or edminlstretive perialtlas up to$5,000 per vlolatbn per day as descdbed In Public <br /> Resource Code section 42962: -- <br /> [ ]Imported Load [ ]Exported toad and Location Hauler Exemption Status <br /> � 1f Address:' [.'j Govemment <br /> [-.j-LEA Exelnpt <br /> City State; ,'•. [: jAgncoltural <br /> .r [ ']Common Carrier <br />