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r WORK ORDER I MANIFEST <br /> 1274877- <br /> ------- <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: /j` <br /> Modesto,CA 95351 City: •..� State: <br /> 209-521-6221 Zip . Phone: ,s / <br /> TPID,-1274877-01 TPI13with Suffix: ^f��J- <br /> Load Date: ` ' Load Typo. ( ]%Ikole ( ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # `r - I [' ]Pick-up Count: <br /> License#: State: Dot Code: RWDY [ ]Delivery Count:_____ <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 way <br /> 15 <br /> 16 �- <br /> 17 R <br /> 18 <br /> 19 d f <br /> 20 <br /> ,r r r <br /> Drivers Signature: ! Date: Customer Signature: Date: <br /> Drivers Name (print) !'-.11i JI„ �' Customer Name(print) <br /> I—fify that urder panty or p&jvey undsr the laws or ft$lora W Collfoatia lhal the mfomnarlon I!xrlify that under pmsaly of perjury a"der Ihs laws of lho$:ale of Calrornia 11•2a thu Infcrmafon <br /> rmvlded above m tin and conocl,In addaon,I em award lhae falsifcalon or isle nformaaon may provided above is true and carrocl.In ad°dan.I aril aware that falvBralinn or Oil infamaaon may <br /> result n suspeni on,revatalium or derial of renewal of the Waste ire Haular rta clraflon pureuehl. result crnl panalles up to 125.000 per day,per vidason or adrNmlralira pa—flus up to$5,000 <br /> lu sne Fvhic Rasourcd Goad samon 4ldtU and me reset n e ht panal0ea up to 525,00',par day, per violation per day—doaeihad m PUMk ReSOufch Cada saclhn 42062. <br /> P"vinlallon or admirialrali e;1 r 11=up to$5.W0 per v{Blebm per Cay as:lescrarad In T'.uLlo <br /> Rewmurw Coda section a2 W 2. <br /> Data7 ( ] Imported Load [ ]Exported Load and Location Mauler Exemption Status: <br /> Vis° N Address: [ ]Govemment <br /> 'q [ ]LEA Exempt <br /> City State. [ ]Agricultural <br /> [ ]Common Carrier <br /> t <br />