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WORK ORDER/MANIFEST <br /> O <br /> 1274877- 6 2 4r 7 8 <br /> -.,or ]Taste Tire Generator <br /> .,y .suck Tire Service Center, Inc. Name: <br /> I <br /> 1407 Lone Palm Ave. Address: , r <br /> Modesto,CA 95351 City: State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ j Pound <br /> Decal # -- - _ [ ]Pick-up Count• ____ <br /> License 9: State: Dot Code: RWDY [ ]Delivery Count:_ <br /> SIZE MFG. DOT# _ TREAD WHEEL COMMENTS <br /> - r <br /> 3 <br /> 5 <br /> 7 — -- <br /> 8 - --- <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 201 1 <br /> Drivers Signature: Date: Customer Signature: Date: <br /> Drivers Name(print) Customer Name(print) <br /> I r`ar10y that under pard3y of p"ry under U"Iowa d the Stale of caftornis that It"informatnn 1 aerfry that 1s ter peraay o1 p")ury order the}awes of 714 ShM of Califomia that ft hforrna6an <br /> pravAicd—9,is ave and corrao.In adc3ow.t am"we Mal!als,iniian of this wo meeon may provided V0044 7ve and correct.In,adintlorl i am aware 0ist falsdiceaon of dais Infornadon may <br /> resuk n cuspa"V w.mwr�Uan,or derlai d r waf of the waala Tire Hauer Raosiration pursuant r"Lit cfvii pmahmc up to$2500 per day,per vK9211011 Of B6min'ai sEve ponallle8 up 10 55,000 <br /> to tris Public Reautirce Code somw 62960 and trey rRsut in wA panamas up to 525.000 per dny, per Mol"tim per day as desaihed in Pubh:Resource Code spm 079-2. <br /> per vt�hefar ar wmtnlatnwve pmar:..`s up to 39,000 par vlolaWn per day as aecama0 in Pude <br /> %ourCe Cede cection 42662. <br /> o��vaq J. [ ] Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> �s Address: [ ]Government <br /> LEA Exempt <br /> City State: <br /> [ j Agricultural <br /> [ ]Common Carrier <br /> C <br />