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09/28/2015 14:36 20952_ _81 MCCOY TRUCK TII PAGE 02/05 <br /> _ WORK ORDER/MANIFEST <br /> a& $q 63 <br /> (VE) 1274877- 7 6 96 6S <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center.Inc. Name1 tq bt- .- <br /> 1407 Lone Palm Ave. Address:A—,;w r{0-o'l <br /> Modesto, CA 95351 11 1 City: State: �iTQ <br /> 209-521-6221 \ ZIP: Pnonea. I"aS)gDq 'S02) <br /> TPID-1274877-01 TPID with Suffix. a.1 - 01 <br /> Load Date — 3 0---J Sar Load Type: Whole Cubic Yard f ITon I j Pound <br /> Decal# / -,,ice-Q L L Pick-up count: - <br /> License#Qty SJ(V State Dot Code: RWDY [ ]Delivery count: <br /> ( J REGULAR TIME ( J OVERTIME 1�CALL OUT CUSTOMER POt/ <br /> FLAT REPAIRS )) ''__ IIe� WHEEL SWITCHES MT/DISMT <br /> LICENSE NO�ikz� S EHICLE MAK7ERE�aILEAGE VLHICLE NO. Q 3 <br /> LOCATION:Vii CWIAOCma vice_ e;> <br /> WORK_PERFORMEO(o �Q .S' -- -0 4 MILEAGE IN <br /> a-NWLArC;[ MILEAGE OUT <br /> _. TOTAL O <br /> TIME IN ��. PtA <br /> Lo095OLOD8 <br /> TIME OUT Q <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> Drlver5 Si nature: Customer Si nature: Date; <br /> Drivers Name(print) Customer Name rent <br /> I ePmn•1111,nyd.Pono'y of pall.ny 1.ntl7l II`e!aws Q(IS"31AM M r0tolPb Ihat Inn 01a11.1M1 I oordfy 0-undo•wo(Ir 9f Po,Ivry vnenr Pa leay of1ho swo of cm,owmla 19e11IIa mbnnanon <br /> PMvWld abavo pun■nd!Dlreet.In add lion,'nm of <br /> h Il�d;(t)1�I641Ibn r.'lN�InfdfMore, <br /> 11 p•nv•I!U eye In;No and rnnrel.In rddllion.I nm nwara Inol'a11:6eelion el IFI,inf—Con'nay <br /> '++M w•, Ron2w r:vowvon.4 naN.led ranewn'of hr.Waob T'q He•fet Regkmation p.rnu.n; re�ylt dN'erca n.�.lp 1p 125.000 pot dlyy.�en•ll 1119]1 edmhlstmipm o n4if ao bn!o f..000 <br /> n In!0uf k Re-ovr:a Coag aaMWI�2P10 and+wy rn+1.e In f•v I pO�aldocf7Mf�1r opy. C9f yda•nn rw nay n1 de-Oboe M P,MIk Raapl,K0 Coda:oC1on AMI <br /> ( .'•'INIt)n Of adnl'NflMl�va ry..-hl+!�d le sd•dOJ pnr 0o af—ft—Aly n'dnae•Iond'n I',.h'1� <br /> RaaN'4 Cddo;ae!Ion e29e7. <br /> �pvcb+ro T� ( I Imported Load ( J Exported Load and Location Hauler Exemption Status, <br /> ?� Address: ( J Government <br /> ( J LEA Exempt <br /> City State. [ ]Agricultural <br /> Common Carrier <br />