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WORK ORDER/.MANIFEST <br /> 12.74877- -44568 <br /> Waste Tire Hauler Waste Tire Generator <br /> a., <br /> McCoy Truck Tire Service Center,Inc. Name: U ✓` ` � u �ti'{w f �ir �' " S <br /> 1407 Lone Palm Ave. Address: Lj _ Lawi.4C <br /> Modesto,CA 95351 City: L � o/o State: <br /> 209-521-6221 ZIP: Y�;310. Phone: <br /> TPID71274877-01 TPID with Suffix:/i/ tjf�' <br /> Load Date:45- !E Load Type: [Whole [ ]'Cubic Yard [']Ton [ ]Pound <br /> Decal # !' 1 t7 t !_ ! Wick-4p-Count. <br /> License#:' , State:C A Dot code: RWDY [ ]Delivery Count: <br /> _ SIZE MFG. DOT# TREAD. WHEEL' COMMENTS ' <br /> 2 <br /> 3. <br /> 4 - <br /> 5 <br /> 7. <br /> 8 <br /> 10 <br /> Vii.• - .. - ,�;_._ <br /> '. 12 <br /> .13 <br /> d` 14 `t <br /> 15 <br /> 16. <br /> 17 <br /> 18 <br /> 19 <br /> 20 f <br /> Drivers Signature Datei -3-1(.. CustomerSigiiature: Date I <br /> Drivers Name(print) j!t��.a. t?f Customer Name(print) w, <br /> I certify,that ander penalty of,perrjury under the laws of iha:State of Calf(omla that the infonnatiori 'I certify that drtdetpectelly of peirJuryunder the 'sof the State o(Call r{�ia page information, <br /> z <br /> providedatiove is Erue andcorrect.In addition;I am-aware that falsficatlon of this information may, provided abovels Gua end correct:in addi6oh,lam aware thaffalsification of dr information maY M ' <br /> result In suspension revocation;or denial of renewal of the Waste Tire Hauler Registration pursuant resulicivll gerietfiea up to,'SZS,000;per day,per-yidafion or administrative penalties up to$5 000 .,� <br /> to the 0ublic Resource Codeseoion 42860 and may result in civil penattl:1 uP to$25,000 peroay, per_vtoietion pardayae described m Public Resource Code section 42962, <br /> f pper violation 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 8ta <br /> Address: [ ]Government <br /> [ ]LEA Exempt <br /> city: ;' State:" [ ]Agricultural <br /> Common Carrier <br /> 1, <br />