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WORK ORDER/MANIFEST <br /> o ( 1274877- <br /> a <br /> Waste.Tine Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: - <br /> Modesto,CA 95351 City: State: <br /> 209-521-6221 Zip: Phone: 't <br /> TPID-1274877-01 TPID with Suffix <br /> Load Date: Load Type: [ ] Whole [ ] Cubic Yard [ J Ton [ ] Pound <br /> Decal # _ - - __ [ ] Pick-up Count: <br /> License Stat <br /> — <br /> RWDY [ ] Delivery Count: — <br /> #: � ;°Z� e: - Dot Code: — — — — — <br /> SIZE MFG. DOT # TREAD WHEEL COMMENTS <br /> 1 ".� { <br /> 2 r <br /> 3 ii f <br /> 5 .5,� •� <br /> 6 'i <br /> 7 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> givers Signature: p, Customer Signature: Date: <br /> Drivers Name (print) ` v Customer Name (print) <br /> I certify that under penalty of perjury under the laws of the tale of Califo tat the Inlormation - 1-certify that under penalty of perjury under the lame.' the State of California that the information <br /> provided above is true and correct.In addition,I am aw;,,W,�1hat falsification of this information may provided above is true and correct.In addition,I am aware that falsification of this information may <br /> result m suspension,revocation,or denial of renewal 91' waste Tire Hauler Registration pursuant result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 <br /> to PLplk Resource Cine section 42960 and may result in civil penalties up to 525,00 per day,per per violation,per day as described in Public Resource Code section 42962. <br /> violat on or administrative penalties up to$5.000 per violation per day as described In Public , <br /> Resource Code section 42962. <br /> [ ] Imported Load [ ] Exported 'And ocation Hauler Exemption Status: <br /> > tQ A Address: ] Government <br /> ILEA Exempt <br /> City: State: [ ] Agricultural <br /> [ ] Common Carrier <br />