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1 v � <br /> I i ll WORK ORDER/MANIFEST <br /> , CJ • <br /> 1274877= 62238 <br /> Waste Tire HaulerYVaste el <br /> McCoy Truck Tire Service Center, Inc. Name: •.� <br /> Y tt I <br /> 1407 Lone Palm Ave. Address: <br /> Modest � -�/ <br /> Modesto,CA 95351 City: C ,� zoy7 State: C <br /> 209-521-6221 Zip: Phone: <br /> XPID712`l4.77-01 TPID with Suffix: <br /> Load Date: Load Type: [r Whole ( ]Cubic Yard [ ) 61a [ )Pound <br /> Decal # - 1 ("c' � ]Pick-up Count: <br /> Lice ns # / Statet� 1 Dot code: RWDY [ Delivery Count:----- <br /> 1 SIS MFG.��'DOT# —TREAD ——WHE 111111111 111111111111111 caIMMENTS <br /> `�`-_ <br /> '' _ � J D 589961�e - IIIIIIIIIIIIIIIII II IIIII a— <br /> 2 �—'- C '�L — _ III III III II II IIII Ili l 111 --- D 58996159 <br /> _4 —.—_ �o� A --- D 58996160 - D IIIIIIIIIIIIIIIIIIIIIIII — <br /> —__ O_ _3 _ �� -- __—. 111111 III II II Ilil 11 111 11 N —__- 58996161 -- _ <br /> 5 �--- ,�� ���" D _58996162 ____-- IIIIIIIII Illillllll IIIII M _— <br /> _ _ -- _--- III III IIIIIIIIIIIIII1III D. -58996163 _— <br /> 7- -—:- --- - _+ ---- - D 58996164—-- - - - - - <br /> 8. -- <br /> -- IIIIIIIIIIIIIIIIIIIIIIII <br /> _ D 58996165 <br /> 9 — - _- /� T __ _ IIIIIIIIIIIIIIIIIIIIIIII _ - <br /> �/�/�/�_ D 5899616610 <br /> IIIIIIIIIIIII IIII IIII I it <br /> IIIIIIIIIIIIIIIIIIill ill co� D 58996167 <br /> ,1 <br /> D 58996168---- ------ -------�- IIIIfIIIIIIIIiIIIiIIINI °�-- <br /> 12 <br /> D 58996169 <br /> 13 <br /> 14 <br /> 15 ---_ <br /> .16 <br /> 17 —_ <br /> 18 -- <br /> 19 <br /> — ---------------- <br /> 20 <br /> Drivers Signature: D ter 1 r/ ustomer Signature: ;lam` Date: <br /> Drivers Name(pri ) t J L Customer Name(print) <br /> I certify that under penally of er the laws of Ure Stale of cal[fDmia that the information 1 eertdy that under penalty of perfury under the laws of the to o!Caldotrne that the wdomtelion <br /> Provided above rs tnre and care In addition,1 am aware Nat felsificatron of Nis inlormafan may '=,2d.Bore to true and correct.In addition.I am aware at IaladKabon o!thio information may <br /> recull in suspension,revocation.or denial of renewaand yl of the Waste Tire Hauor ReeppSralr.sZ ppeeursuant result crud penalhaa up to$25.000 per day,per violalbn of admmutretrve penallba up to$5,000 <br /> tothe <br /> Public <br /> bli or Resource <br /> aCode <br /> p tiones�o$5.000 per uuk in iatwnlpar day as rfpe6u12bed�rr Dey, per vrmlahon per day as descrtbed m Pudlc Resource Cods sedan d2B02. <br /> Resnu-ce Code aecdon�296Y. <br /> Or,para [ j Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ ]Government <br /> LEA Exempt <br /> 6w City State: [ ]Agricultural <br /> [ j Common Carrier <br />