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t' WORK ORDER/MANIFEST <br /> - 7C <br /> 1274877- <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address- <br /> Modesto,CA 95351 City: State. <br /> 209-521-6221 Zip: Phnne <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: toad Type: [ J Whole I I Cubic Yard [ ]Ton [ ]Pound <br /> Decal#-- - [ ]Pick-up count: <br /> License#: stater Dot code: RWDY [ ]Delivery count: <br /> [ ]REGULAR TIME [ j OVERTIME [.J CALL OUT CUSTOMER PD# <br /> FLAT REPAIRS WHEEL SWITCHES MTIDISMT <br /> LICENSE NO. VEHICLE MAKE MILEAGE VEHICLE NO. <br /> i <br /> LOCATION: <br /> WORK PERFORMED: MILEAGE IN <br /> MILEAGE OUT <br /> —.._ TOTAL <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 4 <br /> 5 <br /> fi <br /> 7 <br /> — -- <br /> 8 <br /> Drivers Signature: Date- Customer Signature: Date <br /> Drivers Name(print) Cu5torner Name print <br /> ,r <br /> I cartlry not under penally of perjury uncoa tha law%01 ti"*SIBkr of Celilcrnio Ifs Iha rdnffW.D" I cer*that under pera[ry of parjury under It*ia`av ur Me statin U California that em inrormation <br /> ptnwded aWvo is true and oYtecl-In addtim,I am aware 11,al ralallkate"d itis rdur:nation may pranQyd aWve 18 ryue 8nd caned.In ad6lion I am aware WI fetaiflarinn of Vr6 Informa1101r may <br /> rethll in suspanwon,ravocatlan of derial of renewal of IM Vei"a Tire H2LA"Ra IalraGgn p,reuant rmUl cinl pc ilws up ti 525.000 pet do p1r vidnliory rr odminkdral4p aerd0es up Io 39.000 <br /> is Ih4 ZWk Reeource Code sector 429110 and may r-11 in L-40 psrteides up tie 525,OrT1 rar clay, par N0186W par dey ee dashed Pudk Ara,rrce Code,Secbon 42962. <br /> per vinlahm ar admstlapalMi pero6rs up to S5.00D pw Hda;nn por day as deck+d in��c4,c <br /> RaB<nurce Cad-section 42962. <br /> D��taat� ( J Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Ile fi,; Address: ( j Government <br /> [ ]LEA Exempt <br /> City State: [ J Agricultural <br /> [ ]Common Carrier <br />