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WORK ORDER/MANIFEST ; <br /> CD 1274877- 77-4 { <br /> Waste Tire Hauler Waste Tire generator_ a <br /> vy� ws4crr s <br /> McCoy Truck Tire Service Center,Inc.• Name:. <br /> 1407 Lone Palrh Ave. Address: y <br /> Modesto,CA 95351 City:L,m�-(a State. CA <br /> 209-521 6221Zip. Phone: <br /> TPID-1274877-01 > TPID with Suffix: , "C7 <br /> Load Date.-3:2q, -l:]: Load Type: [ ttole. [ j CuNcNard ( ]Ton [ ]Pound <br /> Decal # t - .t t 0 [4. 01ck-up.Count: <br /> License# #1 �i` staEaZA got Code.. . RWDY :IDelivery.Count:_ <br /> SIZE • . MFG. DOT# COMMENTS <br /> TFEAb. WHEEL..: . <br /> }'. 3. <br /> 4. --- ,. <br /> 5 <br /> 7 — <br /> 8 _ a <br /> 9 <br /> a' 10 _ <br /> 13 <br /> v. I 1,4 —- <br /> .'; 15 - <br /> w 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> }' ;DriversSignataretr- Date - �/ CustomerSignature Date:3-Z�-tt <br /> s f. <br /> Drivers Name(print) �( � �, , Customer Name(print) <br /> 1 I.certity'that under penally ofgerjyry unde�ffieaaws of the State of California that the lnformetion. :.I:cenily thatunder penal%bf perjury:under tha.laws of the,State:Cif- _ t .B I tion <br /> y P pe P .�, <br /> y'• - providedabove,ishue apd,ci?rrecLlpadditron;I am aware that faisffioation d this infomwtlonma nr/ded aboveis true end conBU:.In eddltlon,I am aware thatfalslfiption of thte Infonrlation may. <br /> r re's It In suspenstort,reyacatfon,prdeniel of renewal of the Waste Tire Hauler Ragistrafion pursuant resultalyil penalties up 16$25,000 per day,per violation or administrative. nalt+as u p to$5,000 <br /> •a the PuWfC Resource Codesectiori,42060 end may result in civil penalties up t$25,000 per day, per vio[aLon per"day,as described In Public Resource Cotle section 42962: <br /> pQryblatlon or adminlstra11 penalties up t$5,000 per Llolaoon pair day as described In Public- - <br /> sour:e Code secOdn 42967. <br /> [` ]Imported:Load j E xport6d Load anti Location Hauler.Exemption Status: <br /> Address: [ ]Government` . <br /> 'Ab, [ ]LEA Exempt <br /> City [ :]Agricultural <br /> Common Carrier ' <br /> :;moi .�l•'� +;k' .`. <br /> .sr'•+:`_ a�� � .tee:. .S`r;.v: <br />