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t t, WORK ORDER/MANIFEST q <br /> 12748777. <br /> Waste Tire Generator <br /> Waste, ire Hauler . • <br /> McCoy Truck Tire Service Center,Inc. Name: re✓ 0✓mss��nalui E>4. 4Jes i <br /> 1407 Lone Palm Ave. Address <br /> Modesto,CA 95361 <br /> City:(„ {-gyp State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with.suffix:f q - <br /> Load Type:. hole Cubic Yard Ton Pound a <br /> 'Load.Dater _1 �. ( YP [� [ ] [ 1. [ ] <br /> pPick-up Count: <br /> License#: i+ g State:(A Dot.Code: RWDY .[ ]DeliV@ry Count - <br /> ,. <br /> _ SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> �? 4 <br /> 5 <br /> t <br /> 8 <br /> 10, <br /> 12 ti <br /> r 13 <br /> .14 <br /> 15 <br /> 16 <br /> 18 <br /> 19 <br /> 2Q <br /> Date <br /> D`rivers:Signature Date:#-I$-lt Customer,Signature: <br /> Dfivers'Name,(print) .(:icL.+A�:� b. tG�-( 1 Customer-Name(print) c;. <br /> 'I ceiM1fY that under penehy,of penury under the laws of the State of California that the Informatbh .I certify that under penalty 81 perjury under the l-11 the State of alilo -t the information <br /> provided above Is true and correct„In addition,I am aware that falslflcatlon df this Intomwtion mayprovided etwve'is hue and coned.In addition,I em aware that falsification d this informadon may <br /> '.result Irtsuapansion,revocation,or denial of renewal of the Wae(a Tire Hauler Reglspatbn puisuant result dull penaltiasvp to.$25,000 per day,per violation or administrative penalties up to$5000 <br /> - to the Public Resource Code sedion'42960 and may result In clvll penjiss up t$25,000 peCday, peaviolatlori:day es dascdbpd In Public Resource Co.bisection 42962. ” t <br /> pper violation pt_administrative penalties up to$5,000 per violation,par day as described in Public -gr <br /> Code sedan 42962. <br /> [' ]Imported Load .[. ]Exported Load and Location Hauler Exemption Status.;, s� <br /> t t ; <br /> CstFq�' Address [ .]Government <br /> [ J.LEA Exempt <br /> City State:[ ]Agricultural <br /> ]Common Carrier <br />