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D Q e f WORK ORDER/MANIFEST <br /> 1274877- <br /> Was Tire Hauler Waste Tire Generator <br /> McCey Truck Tire Service Center,Inc. Name: e' W, �1 <br /> t « i t <br /> 1407 Lone Palm Ave. Address: t?, N, a y i)r . <br /> Modesto,CA 95351 City: ��vt 1��G State:, <br /> 208-521-6221 Zip: et a t-k, Phone <br /> TPID-1274817-01 TPID with Suffix: <br /> Load Date Lead Type I I Whole [ ]Cubic Yard [ j Ton [ ]Pound <br /> Decal # - [ ,]Pick-up Count: <br /> License 4. State: Dot code: RWDY [ ]Delivery Count:_ <br /> SIZE MFG. DOT# TREAD 'WHEEL COMMENTS <br /> 1 <br /> /7 <br /> 2 <br /> 3 f ' <br /> 4 <br /> 5 <br /> 6 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> i6 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature: _ Date: �� �, Customer Signature: Date: <br /> Drivers Name(print) Customer Name(print) <br /> I aero ft tunpgr pertly of perjury under Il+n town al the VAID of e4iferne rtet Pte Inforr:rn0nn I cerldy that undo penally of Pori"under the IBvve of jure SWe of Calkn-iz:nal t-*fttnttdhn <br /> prey idld above la true and¢free.In addtlk:n.I am a.&*mw ralsificaBan of IFjs mformalnn may p oohed aDave is I"and carred In addition,I am aawars IKel IelelfcaBa,of this rdarrrwtnn tre y <br /> rasull In eUaQerejo n,raw !Jnn,of denial of re-intal of Inc Waale Tre Haulat Reg;0walicri au'suars restA av0 onnadles W In 525,170:1 rw dsy.per uiobo nn nr atrninnoaove I+oneOe.f W is 55.000 <br /> to the Puhlk.Reaourca Code saetan 47x60 and troy n esu4 m WA par'2z"up to$25 a-000 a day, per 0obbon pv day as doocrbed in Ptnle Resaurcn Coda section 42L+d2. <br /> per widation of adminislnRne pararlas up to$5,000 per vblallat per day as des--ibed in Plblc <br /> Rescimm Gala eectien 42862. <br /> Q�t,�uara Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ j Government <br /> [ J LEA Exempt <br /> City State: [ ]Agricultural <br /> [ ]Common Carrier <br /> a i <br />