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11/03/2011 13:23 209-521-F MCCOY TRUCK TIRE PAGE 01/01 <br /> Z� G 3 WORK ORDER/MANIFEST <br /> T=7 <br /> 1274877 37 0 7 0 <br /> WaAt�T�.H®ulfar <br /> e <br /> McCoy Truck Tire Service Center, Inc, Name-. <br /> 1407 Lone Palm Ave. Address: /�' ��. <br /> Modesto, CA 95351 $i Clt : `p <br /> 209-321-8221 CJS'` Zip: � � Phone' �V,�����// <br /> TPI -1274877-01 TPID with Suffix: ''B✓ <br /> Load Date; Load Type: WWhole [ Cubic Yard [ ]To Pound <br /> 17 <br /> Decal # - -Z Pick-up Count: <br /> Licena / Sty; Dot Code: RWDY Delivery Count; <br /> SIZE MFG, OOT# TREADW L COMMENTS <br /> 8 <br /> .fid„__,....._., .._.. .. . .. .. ._.__•._.._.__ ..._...... _ .. .... ,,. .. .. .. .... .. .. . <br /> 14 _.. ..._.. _ _. <br /> 15 <br /> 17 <br /> 1® <br /> 18 <br /> 20 <br /> Drivers Signature: V,411 Z2 Customer Si nature: / Date: <br /> Drivers Name pd Customer Name (print) <br /> I Zify VV' peim�of vl Iho In—or Iho Sudo 0f CaIFDV 10 M Ino WINI 101bn 100 "1q Yn011r P-11,y et pwhuryq undl-mw www nr 1,r and ns,w�u7n10 I In U nllnn <br /> IIrum.d RnIMI I}inw 4110 COn v1 lmm��n.1 mn awar9 tIIM rerrmcs110n or I Ie IMOrrnllltln may d 1 11 Inc an ognvQt,'In wddman.I}1n awmw mar(Itl01tlM111An nr In�911tlM1Ml M <br /> Brum In!uev n!fm,r�xenon.d.denal of romwN or me Wa^IeTln,rfdular tet rtlal olrtsunn ioau#�a,n onrwmnn u�ro`I ao.eoo vw�nl�,I v A411nn M AOR1W41R11"og�!nn, w ro BR�I� <br /> to IhS P�bl1. ��a•cp Coda mellon a2Bti0 oed n,ov nsa�M,n O•A vr•,nlna}�n 1- .000 P dM. Pm vibWan par E11y w e- lhwl M MAI)M+M1n'!e�Me—d—� <br /> pef�VfOkRbn a�efanIn101ro0y0 De�Mlllep up fn 00,000 pw vinllrlon am Ary AS dQXYftd In Pudic <br /> M0111M OOtl�n1l:llon 4AINi1, <br /> safe <br /> [ Imported Load [ ] Exported Load and Location Hauler Exemption Status; <br /> �a�j4 Address: [ ]Govemment <br /> X206%— <br /> e [ ] LEA Exempt <br /> City Stet®; ( ]Agricultural <br /> Common Carrier <br /> Received Time Nov. 4. 2011 1 : 21PM No- 2465 <br />