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09/28/2015 14:31 20952_ _81 MCCOY TRUCK TI'i PAGE 01/03 <br /> WORK ORDER!MANIFF_5'T <br /> i <br /> s 1274877- 7 0 5 9 2 5 <br /> Wante Tire Hauler Waste Tirn annerator <br /> McCoy Truck Tire Service Center, Inc. Name-'►N JJ„ <br /> 1407 Lona Palm Ave Address.'05b 0 <br /> ,AO 1do �J <br /> Modesto,CA 95351 City`ty k.."I } State• t� <br /> 209-521-6221 zip. "'15')r'4 Phone*, tel <br /> TPID-1274677-Di TPID with Suffix: WIL 1 <br /> Load Date; Loed Type: Whole Cubic Yard Ton I I Pound <br /> Decal#1 -- -q--"tz- [-4Pick-up count: ____ 1 <br /> License*. 10 state A I Dot Code: RWDY [ ]Delivery count: _____ <br /> J REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER POtt <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT_ I <br /> LICENSE NO VEHICLE MAKE MILEAGE_ VEHICLE 1\107_(Jj_ � <br /> LOCATION: J <br /> WORK PERFORMED: P[gI(AC� 0 ft— _��O.Wl.r.�.. .t7 v� �1'(et.. MILEAGE IN <br /> L FA,0 MILEAGE OUT_AA-414 <br /> TOTAL.. . . . .. <br /> TIME..IN . <br /> _ _.._ .. J ---- -- ..�oN`(►tc�e 10 ; SS Alm <br /> TIME OUT . <br /> SIZE MFG. DOT;4 TREAD WHEEL COMMENTS <br /> 2 _.. ...__..... . - - <br /> 3 <br /> 4 <br /> 5 <br /> 6 _.--..- ....... . _ . <br /> 7 <br /> 8 <br /> Drivers Si nature Dote; Customer SI nature Date <br /> Drivers Name(print) Customer Name(print) <br /> I cer"ry Ihat urdof Danelty or a ry anon'Mo la of,r 91•.nt Gnrnm.•I",In!INn•teetren I GenVy 1641 urd0r Dona'1y or Po;ury i,ndar W Iswlt of!ne sU a C�I•feTIA Ihel Ine'nfomudor <br /> nroin•n nnnw a my!Inn COttsnl In 1<Witlon,I •ware!hat fa''sifcoU0r d the Mformadon may am.n•n ab!w•41me end co+w.In wIt or,I V n owro Ihet faorlmallee orm.trrolmminn may <br /> rs•ur In susnenaa`n ra^ocN�Dn,or da nle!d wni of tan waaln T—Nnalnr R lrrrm on p�lm�•nt .•.;!rlvil DenArna Ira to 523.000 Dor day,oor vwlneon or adwIN-11"11"prvt "in to�c moo <br /> IU II`e r U41Y Roe Dvreo Code vection ei9G0 an0 mny Ia:Ull In f.Nl'pnnnroan un to 7i,1f0� N N y .r vbHllon Der day no de:cnDeo it PyD�IC Rn adLrM CON upinn 4)011 <br /> 1111 v elnllnn nr r1dU+ln;>ynnv.pl%$ase tM M SD1,000 Cef Va at an oar diy.)3 dV9'IDrn In I'11M C <br /> P•mdr•Cods e•511on n29e2. <br /> op�cP�cl) ( Imported Load [ J Exported Load and Location I Hauler Exemption Status: <br /> Address. [ J Government <br /> 1, <br /> f I LEA Exempt <br /> City Stale: [ J Agricultural <br /> Common Carrier <br />