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11/03/2011 13:02 209-521 1 MCCOY TRUCK TIRE PAGE 05/14 <br /> WORK ORDER/MANIFEST <br /> 274877- 20166 <br /> 1Na41xe Tire Hauler WaSte Tire Gen or <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address �a <br /> Modesto, CA 96361 city:a�1a',, Ste C/04 ? <br /> 209-521-6221 a' zip; F� Pnone: <br /> TPID 1274877-01 TPID with 9uftlx 3 <br /> Load Date: �� Load T e: Whole ]Cubic Yard Ton Pound <br /> Decal # 6.�3 F 1% Pick-u Count: <br /> License Dj IStat Dot Code: RWQY Delivery Count: — <br /> $I G- DOT # TREAD EL COMMENTS <br /> 2 � , <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> oe8 <br /> 9 <br /> 1 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Driv®re Signature: fj Customer Sign ure: �� 'A Date: <br /> DrWers Name pri ) ,j Customer Name (print <br /> I Apaay Ulpr vrf,r P!r,l'ny elYndar IT10 Ial1a a al cmnbmm ITIM TW InIOdMlan I er"My 1"t undal p4reM 01 P"try MIN Ole lege ul the WS0 b 111 Vrna mai mo lmormn m <br /> provideG ot, k Wo nntl In eadlrlap,1 Ivo ff"M Tun Analpeallon of MM IMixmAllen rosy pro,Ans 1 Abr"4 MIo Md aone0l In bdd01on,I em mvera Ort lals aOar c11110 n"116an MW <br /> fmft h eusmmren..eym nM ar danrll a ramlwnl of M WnPta 1ha MaDAr PM!PlfA! - Ixlnlmnl Rauh In&11 panalitae uv to%1"000 oor dM,00r vloletlon or oarrArtlrnamla PWMPP W b l�.nno <br /> W Pndlr.Rafmlkc Crfp eanprl A2pM OM A»y IMUII in MIM peMI M"R.525000p�day,Oar ear vblatlon Dor day;rdaCV11DQa In F,11540a 1n RmOur C0d1 walµN AMAR• <br /> vinl(.Tlw d 7tlr111rg9pp11w�gfl�µl�p Ip k.l5,DM pM v)518 en per day as da rlbod m AwIc <br /> Odda seed..02N2 <br /> vat [ ] Imported Load [] Exported toad and Location Haulor Exemption StatusAddress: [ ]Government <br /> [ <br /> ILEA Exempt <br /> City: State: ( )Agricultural <br /> ( ]Common Carrier <br /> Received Time Nov, 4. 2011 1 : 21PM No- 2465 <br />