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V <br /> WORK ORDER I MANIFEST <br /> 1274877- 7' <br /> Waste Tire Ha,meter Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name. <br /> 1407 Lone Palm Ave. Address, <br /> Modesto, CA 95351 <br /> City: State: <br /> 209-521-6221 Zip: Phone, <br /> TPID-1274877-01 TPID with Suffix: <br /> t oad Date Load Type: [ I'Whole I I Cubic Yard I I Ton [ ] Pound <br /> Decal #- - [ ]Pick-up Count: <br /> ISri r Dot CDde. RWDY [ ]Delivery Count-- <br /> SIZE I`VIFGt.G T TREAD WHEEL COMMENTS <br /> 2 <br /> 4 <br /> 8 <br /> to <br /> 11 <br /> 12 <br /> ...... ............. <br /> 13 <br /> 14 <br /> .1-5 <br /> 16 <br /> 17 <br /> 18 - <br /> 18 <br /> 201 -'d <br /> Drivers Signature: DateCustomer Signature: Date: <br /> —Dnvers Name(print) Customer Name{print} <br /> I 'n'.t. P*AaA)Q1 jwtarr Ih M She <br /> ortvdod omv4 is tear ftfj NO ishf)"unn'A 1wl fnf'uth�may =W=rvue nct�,"l 1A addAi=A 11m.AwwP Oh wwkwoh a ohis WAwnwiDo mmy <br /> Ip tib <br /> 1p= <br /> ,�'faqly ftV%thMW P�Xlkfifa*" MOO CW Paha"t UP to$2�1 WO Dot day.Per yralaWl" nl=?"—L40 J*16,0W <br /> =cn.Of demw Of teww"of ttW 110MO T'11*11OU'm' <br /> ft bect-on 42NO and nay foeum"m4 p-ratos *lo,52L�Yj :my Pat vkdwoaft per day as ow,rumd pahlr pbesewca I= <br /> per 14"up rb 55.030 Par"o4ation 061'day as dewo <br /> Imported Load Exported Load and Location Hauler Exemption Status: <br /> Address: [ ]Government <br /> WIWI [ j LEA Exempt <br /> City State: [ Agricultural <br /> Common Carrie., <br /> ..........- <br />