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�xDec. 19. 20''. 3= 2 ; 21PMG7-0Ll—bLtll �`'ILIUT IPfuIK IlltC L,No, 3019, �P.l�\�I3�+ST <br /> WVI.I.VI.V1_Rlf,l/ 'GST <br /> 1274877- <br /> 69121, <br /> 0 <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Sewioe Center,Inc. Name: <br /> 1407 Lone palmAve',- '��,' � AddrAPe <br /> Modesto,CA 85351 City; $��+�� State: A G11 <br /> 209.52T•62211 <br /> zip. <br /> ( 0`� <br /> p 5;x,1 Phone; <br /> TPID-1274877.01 TPID whh Suffix; I <br /> Load Date: )J-Z'5113 hoed Type: I Whole C CubroYard Ton f I Pound <br /> Decal # ( j_. ty O 4 [ PIek-up count: <br /> License#; 751 Sta* Dat Code: RWDY [ ala®Ilvery count: <br /> (�REGULAR TIME ( J OVERTIME ( )CALL OUT CUSTOMER Pont_ �(p 13-C <br /> FLAT REPAIRS WHEEL SWITCHES MTlDISMT <br /> LICENSE N0.316 93 VEHICLE MAKCTPLt- MILEAGE VEHICLE NO_ <br /> LOCATION: �3�h� C� Wln'bVGC Q ZAS C�M Mt (� S <br /> WORK PERFORMED; LA� �P_ "� Pp��s� ' �' „ MILEAGE IN 2 <br /> _..__......._ ..._.... --.._..... ' z 3 <br /> \ 1�� � ^ ,.,...,.,,_,...�, LE G�OUT.,_.......----.......---- -- - - <br /> 1 CSS , `'q� ��� C-� r,��. M I A <br /> ...._..-......... --- — ---._ ._._ <br /> _... <br /> � A,� p �. �: . �yU TOTAL.._.._ <br /> -10 .,,1.1..1:C.611-1 <br /> TIME IN <br /> .. . 1 1 1111,. .1._..1.1.1. .1......._.11_....1_.11...11_......... ._._1_..1...111 111.1111._.1._,1.1.11..1.111 111 111.1....1. ..._1...._..........1.._._. _.. _ <br /> TIME OUT <br /> SIZEMFG. DOT if TREAD WHEEL COMMENTS <br /> �..1_ ... .....1._...__.-.1� _....`_1.1�__. 1.._._..1....,_._ 1.---------......_.1....1 ....1_....- ..11.. 11.11..1 11..1_.....11,,_.....1.1_11..._..... _.1_...._._... ._...----._..._.._._.... _.......... .. <br /> _ 11. 1 <br /> --...- ---1........._1.... ......_.1_..1.._..1._ .........11.111.11.1 . 1.1.1.1111.....1, 1_.. .1. . .....1.__.1.1- �— -- -----------..._......_..._. .. .. ........ ...__..._._.._._..._... .. <br /> .. q <br /> 8 „l- <br /> 7 <br /> 8 <br /> Drivers Signature: - Data: Customer Signature; Date; <br /> Drivers Name rl CuelomerNeme dnl <br /> I avA Dl u�m udar Denalh of paeuy hider Yro kms d Iha&ale d CeRfr.va that lh lkww•wv^ I pmNy INn und.r panaRy of D•�Y unoa IM leve d If1e 14*01 C I thv hlanrnlbr <br /> d e a U.r arld amraet.1n Dd®to, <br /> I MI NWgn MUI 1e W MrM++ilDn me awned Dwa h tn,.aid aYr.�.,n oddlimn,I am aware anal IetyDxtlon Ntrki fAfarmauan Rv+y <br /> ro6V>t�1 ODjDObrl�O�IOn,0p��60^I�tOe relrwN of IM wP,%M 1414L <br /> NnV{ot AppOlTtAf�yugVbtl RwR dvU p01 /0 up too==pd oay,por nOw a odyn blmHve POrWkD Iq�;+S5,;Do <br /> No RI b Revou ee0s0a A2 r•d nu•raiudl,n ebd p.nM,oa up ro S7i.DOD va aq, ow vlabyan pOr iry Of tleye,�yH(M PI1M10 �IOINOa OoA•p.C11on�?36l. <br /> tpoa`ble ar edrt.b,lel De�Riea W la SS.00�P•r Hnwuen uv�day oe neacrmoe n Futile <br /> ReoouK!CoOe eediaa a.,, <br /> ( )Impotiod Load ( J Exported Load and Location Hauler Exemption Status; <br /> %L Address: ( I Government <br /> f� [ ]LEA Exempt <br /> City 9tfjle: ( ]Agricultural <br /> Common Carrier <br /> 1.1..1... ......_._.1..1.......�. 1.......,..-. . . . . .... __. 1 1... 1 1 1 - 11 1 1 1.11.. .. 1. <br /> Received Time Dec. 19. 2013 2 : 31PM No. 0911 <br />