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09/28/2015 14:36 20952 -81 MCCOY TRUCK TIi PAGE 01/05 <br /> WORK ORDER!MANIFEST <br /> - o <br /> 1274877- 7 7 318 <br /> (oG SI <br /> Waste Tire Hader Waste Tire Generator <br /> McCoy Truck Tire Service Center,Inc. Name: yq4 Pell I-Ae/.R�//yjf . lN C <br /> 1407 Lono Palm Ave. Address:aO ! '296 14 d 1( , `� <br /> E8 1 g 2915 Modesto,CA 95351 City--t me/(�/ State:( p� q <br /> 209 .6221 zip: <br /> -521 (I C -(O / Phone:)''O�' <br /> 1 TPID-1274877-01 TPID with Suffix: ILV ,Q <br /> Load Date: Load Type: f kAole I I Cubic Yard Ton f ound <br /> Decal# -Q [ 10ick-up count: __ _ <br /> Lice se 1 State Dot code: RWDY [ )Delivery count: _ <br /> [ REGULAR TIME [ J OVERTIME ( )CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT— <br /> LICENSE NO."/,, VEHICI.E MAKE MILEAGE_6,2Y?4 VEHICLE NO. a�Q� <br /> I <br /> LOCATION:/v/ <br /> ,/I,�. P <br /> WORK PERFORMED: _ MILEAGE IN <br /> S_ /, T ILEAGE OUT f��Q <br /> TOTAL <br /> 0 co <br /> TIME IN <br /> TIME OUT <br /> _— SIZE MFG_ _ DOT# — —_ TREAD _ WHEEL — _— _ COMMENTS <br /> 2 <br /> 3 - – of C� l e_... _ —. <br /> 4 <br /> bead—..Cau�sr -- <br /> s ---- - --- - - do <br /> _. - ---5 �--=— ---. - <br /> 7 <br /> 81 <br /> Drivers Signature: e; — Customer Signature: /- Date: <br /> Drivers Name rent Customer Name(print) <br /> �- <br /> I ccnUy Inst un(1p pen111Y or ppr)ury IrnWr the p o 1 Id of .'rrnma I N IRe Irfo don I cendy Ihet.-dor o.nwty nr poluY ucdsr rho' .of In.81016 of GIHDMo Ihet Inq Intopnff.e� <br /> rydvrdetl ebo-p t eun.rtd oorr9Cl.In ptldll:On. nm qw. lnpi feh16ceP.on d Ih:Inb�m.ncn 1— pnnAdnd.b—ry rule ped ccrmcl In.logon.I em 6wa,o In6t fn'.Ipc.gnn of rnY Info, ptlan In. <br /> resuh In.U.p.Won.rW6ulion,a dan41 or.'-@I of <br /> Inq W0.10 Tim Hqul.t Ii.gleppl on aN.oni ,.u6!civii perte4iep up m 125.r)r per to r vont on or.dmin{IIaIWe pineltlo•,up le Ss.pp? <br /> Io n6 puppp Reteurce Godo.oc an.?w Mu Tp Ie.up In cYl p.n.iw..,o b 1b d 1, ppa any. Mr-Wollon paroer na dgtprlp.n In public Rospurco coo.+.rlinn n2i62 <br /> o.r r ..C nr.nmM4epUp pennn o•W to PAN' an per Oey..rN.r,•+b.d In Fuo"c <br /> Rewuro.Code 1eClbn 62902 <br /> D44 p [ )Imported Load ( J Exported Load and Location <br /> Hauler Exemption Status: <br /> Address: <br /> ( J Government <br /> 1 <br /> [ J LEA Exempt <br /> City State. [ J Agricultural <br /> Common Carrier <br />