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09/28/2015 14:31 20952 _81 MCCDY TRUCK TII PAGE 03/03 <br /> r- _ WORK ORDER/MANIFEST <br /> 4)v <br /> - 1274877- 7 5 0 2 9 5 <br /> Waste Tire H:aular Wastg Tire Generator <br /> McCoy Truck Tire Service Center,Inc Name: �A,'nEu. <br /> 1407 Lone Palm Ave, '1� Address; off• <br /> b5-� ��'( ' 1�Q. <br /> Modesto,CA 95351 v� chy. >1 State: CA <br /> 209.521.6221 {� Zip: Q 5OT Phone: <br /> 7PID-1274877.01 1 TPID with Suffix: I LgaOIDA— Q <br /> Load Date' Load Typo—)(]Whole Cubic Yard Ton I Pound <br /> Decal #1�-Q _ [)dPlck-up count:———- _ <br /> LicenseIState: dA Dot Code: RWDY [ )Deliverycount: __——— <br /> >kREGULAR TIME ( ] OVERTIME ( ]CALL OUT CUSTOMER PON <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> LICENSE NOC VEHICLE MAKE" MILEAGE VEHICLE NO. 90S <br /> LOCATION: fx- <br /> — fZt'.�.....-----... MILEAGE IN... . . . <br /> WORK PERFORMED: ���_���_-- _ _ _. _ <br /> MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL _ COMMENTS <br /> 2- ------- --- - _--- -— <br /> 4 <br /> 5 <br /> 7 <br /> 8 <br /> Drivers Si natur Dat a- (p Customer Si nature: Date' <br /> Drivers Name rine Customer Name(print) <br /> I cor6fy that ardor ponn ty of portury under the lows of the Blsto of Uftmlo that Inc Wotmauon I oahlfy Inal urdar ponatry o!par"urdar Inc laws of I+O Btak of C m+orrvn that Inc,wormnllon <br /> ptOdd Ild 600v6 6111,'6 and WWI.Ir AMID".16m 6w6m 2,01 UIj1ro$udn p1 Ino Intel id obOve'1 Itus end Corina.In eddtlon.I sm 1vlam Irel I641fc3tlon ol+hH Infor+Ioim++ov <br /> mDull n nnrlan,revoco!vn.or don Olaf mnawal of Rho Moto Trp Hausa l oglseal'a"pu. rosuli DA ponsltas up 11620.000 va daayy ppa0r vla'auan or admmavncoe ppsnoluu up to 65 000 <br /> to tM ouotic Roroum Codn+aplpn 47960 ane may insult In cNli psnsatu t,o 1312A.{24,000 pst day. Dat vlalmon Dor day ar Osrcow Pn PuOr.c AMDUraa Ceaa ladlldn 12t>et. <br /> wp Voiatldl or aOr"InMYOW s 0e+0iass Yo to Sa.00d por vacs m D«ear as descnboe In C�.pI1c <br /> Po+aurae Coda rnaan 12962. <br /> off'°■of p ( J Imported Load ( ]Exported Load and Location ( Hauler Exemption Status: <br /> 0 <br /> Address. [ J Government <br /> [ ]LEA Ex9mpt <br /> City State: [ ]Agricultural <br /> Common Carrler <br />