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11/03/2011 13:02 209-521-Ak MCCOY TRUCK TIRF PAGE 08/14 <br /> ^ e vvvetn ur�uer�i rvlr�rvlrea I <br /> � � 1 <br /> IT <br /> • 1274877- 5 8 74 4 <br /> Wase Tire Hauler YVaate Tire Oonrat= <br /> McCoy Truck Tire Service Center, Inc, Name: aov-ow� <br /> 1407 Lone Palm Ave. Address/agn"D7 <br /> Modesto,CA 95351 Co City; Stets; <br /> 209-521-9221 zip: Phone6lrt �/ 49 ',,3 0c. <br /> TPII)-127x877-01 TPID with Suffix: `�' <br /> Load Date:B " ` Load T hole Cubic Ylard Ton I I Pound <br /> Dee aI# --i�ft2 AS ick-up count: <br /> License#• 6- 07,,l e,Bw:� Dot Code; RWDY [ ]Delivery count: <br /> [ I REGULAR TIME ( ] OVERTIME [ ]CALL OUT CUSTOMER PO* <br /> FLAT REPAIRS WHEEL SWITCHES ®� MT/DISMT <br /> LICENSE NO./ ' VEHICLE MAKE MILEAGE VEHICLE NO. J <br /> LOCATION: 7IY <br /> WORK PERFORMED! MILEAGE IN S <br /> . (�/ ., ...,. _ ._, �j�Ifjl�l.S1�91P�f- �! MILEAGE OUT <br /> TOTAL <br /> TIME IN AV6129 PP -1 <br /> TIME OUT <br /> IZE MFG. OOT# TREAD WHEEL COMMENTS <br /> 2 <br /> 7 <br /> 8 <br /> Drivers S nature: Gustamcr Sl nature: '- <br /> OAvem Name rint Customer Name(print) <br /> 1�pl��r Ihg1 IulOerennehv u�JIM haws M Ina Rlala nt tlllllbnla that IMI MIIDIIMDDn I cartfN Ilml under ponalb of perlul 1�t n IfbTMI In n <br /> p10W4Dd�bW016 fns�n.Q eMed.�n fnr,I and Mowll Ihnt AIIIIbIROn of Imht hlfORtl�lOn Illny prouloeo DEo•.,a m..Ann o.,.�, nn Ion,I mn nr�iv mlal melon al lnle Inronr�pon n'�r <br /> MIRIAI el i1E0onclan,rvvpolbn,pr din AMwI.M..la M W1uMt Rep vllAlton ur�ute'1t rMUll doll penalller w to S25 009 per Oey der vlounlar nr minlammvn amaq In tv 3L,Qo0 <br /> ID pw PVIMt:AnnaurDa CDa�aaollDlt Tsl and fn0y Maul{M dug WOO u0 b�s,no0�nny, par vlagopn par dar w daao�baC In Publly Re+OUrol�?040 MOUOn�2QN� <br /> p(•r o.-nlwlnh1'43�nx"up to R.0D0 per vtdotlon per day ee derci"O fn Aft <br /> �avrp/ eeclron 4 <br /> [ ]Imported Load ( ]Exported Load 2nd Location Hauler Exemption Statue: <br /> A <br /> Qarv�1 Addmos: fl J Oovemment <br /> h ( J LEA Exermpt <br /> City State: [ ]Aprioultural <br /> common Garner <br /> Received Time Nov, 4. 2011 1 : 21PM No, 2465 <br />