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v 7 <br /> ® okWORK ORDER/MANIFEST <br /> ' Mir 0 <br /> 1274877- 44702 <br /> Waste Tire Hauler Waste Tire Generator - <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> .r <br /> 1407 Lone Palm Ave. Address: "e 4h j M cpt? z <br /> Modesto,CA 95351 City: Lr State: ' <br /> 209-521-6221 Zip: j=� Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: -- :– % /Load Type: [.,]Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # - [ ]Pick-up Count: <br /> License#:'=.;+;`6� t, State:(f�T, Dot Code: RWDY [ ]Delivery Count:_ <br /> _ SIZE MFG. DOT# _ TREAD WHEEL COMMENTS <br /> 2 <br /> 3 <br /> INK <br /> 5 <br /> 6 <br /> 7 ;i— -- <br /> 8 _ <br /> 9 - <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 . <br /> 15 <br /> 16 51 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature,' Date: f Yom` tomer Signature: Date: <br /> Drivers Name(print) , ': Customer Name(print) <br /> tcortlfy that under penalty of perjury under t je p to e o Iforr)fa that+Bia infortnatlon 1 certify that udder penalty of perjury under then awa of the Steto of Cellf a fSia - <br /> provided above is true and correct In edditlon,I am aware that falsificatlo of this information may provided above IS true and correct.In addition,I am aware[hal falsincauon of th formation may <br /> .result in suspension,revocation,or dental of renewal of the Waste Tire Haulerltegistration pursuant result ciyi penalClesop to$25,000 perday,per vidatlon aradministrativepenaltlas up to$5,000 <br /> to <br /> the Public Resource Code section 42950 and may result In civil peneltles up to$25,000 par day, per violation per day as described In Pubfic Resource Codesedbn 42fl62. <br /> - per vidatlon or administrative penalties up to$5.000 per violation per day as described in Public <br /> Resource Cotte section 42962. - - <br /> [ ]Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ ] <br /> Government <br /> [ ]LEA Exempt <br /> City State [ ]Agricultural <br /> [ ]Common Carrier <br />