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MCCOY TRUCK TIRE PAGE 04/14 <br /> x.1/03/2011 13:02 209-521-1 , <br /> a �J WORK ORDER/MANIFEST <br /> O <br /> 1274877— 35485 <br /> Waste TIreJJ.auler <br /> McCoy Truck Tire Service Center,Inc. Name: <br /> 1407 Lone Palm Ave- ` Address: lX-<'� <br /> Modesto. CA 95351 �1 City: State_ <br /> 209-521-6221 , Zip: �� ®Phone: ,71 ?d 2"i 7vl <br /> TPII7 274677-01 TPI D with Suffix: <br /> Load Date: Load Type: whole )Cubic Yard ]Pound <br /> Decal 4 Pick-up Count: _ <br /> Li rte State: � Dot Code_ RWDY ellye CoU t:,_ _ <br /> SIZE MFG. Ddr# TREAD WHEEL MENTS <br /> RT <br /> 5 <br /> 8 <br /> 10 <br /> 12 <br /> 13 __,... _...__ ,._.._..,._..., <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 20 <br /> Drivers Signature: ' lcaofllp Customer <br /> Drivers Name prin Customer Marne(print) <br /> 1 wr1w 1h41 unCar ppomrnlnTf ora■ vw■w■or ero 91414 of C■Ittorn14 tMl 4 MMnn■Ilnn MMfr aha!uMet slyM os tiv rca-v ma alab�or mllb��■lhwt ma fnTa mnlion <br /> pf0■1E d CIbPrO h In a ned ee am aw■n mat MAMICAtl010r IhIR HlromrHlrn T apr�mvN�tlw soma d fit u9. SddlHOn ICM O�n 0 fYSI}71CMIR1tlen e/Ihd Inlomulrbn AM <br /> roau4�n w rnvmauon,awarftl or rmaml or ma W■MA T"Mal141 R4 Mnrrrrfn nr hn,ill ravel penelEdB�0 p4L day p��Pwtivn a yEmiMatratNo pen■lnrrn up M SS-DW <br /> m mn Rlltill R■■nier>*0004■■orlon 4v1sm wrM Tq re6�m rr1 d�H p+.nnmM Up fA QW rinr. Pr�ldA-ver daY ee doxn m PUDIIe Rrraurca CaQn 9rICtIOn 47HA9. <br /> o••Id�kbp er edmMbbelhe penaltlea�p ry$5.000 ver vldallvn Car de l 7R d4 ee In Ilo <br /> noaouroo Coco xnlon 42962. <br /> ] Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ ]Government <br /> [ ]LEA Exempt <br /> City State: [ ]Agricultural <br /> Common Carrier <br /> Received Time Nov, 4. 2011 1 : 21PM No- 2465 <br />