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� � s <br /> ' 1 WORK ORDER/MANIFEST <br /> � O <br /> 1274877- 62 2 11 <br /> Waste Tire Hauler e Gengrator4 <br /> J�/ - <br /> McCoy Truck Tire Service Center, Inca Name: J �( /) <br /> 1407 Lone Palm Ave. Address: <br /> Modesto,CA 95351 City: )i; 7 State: <br /> 209-526221 Zip: ��� Phone: % --::7 <br /> PID-1 4877-01 �. TPID with Suffix: <br /> Load Date: �/ Load Type: i Whole [ ]Cubic Yard [ ]T nf ]Pound <br /> Decal # - ( fes' Pick-up Count: <br /> Licen #. State:L Dot Code: RWDY ]Delivery Count:r <br /> — - ✓�S'IZZE,, FG. DOT# _ TREAD WH�-E-L_ _ COMMENTS <br /> 3 _ <br /> 5 01 <br /> -6 --- — — .7- <br /> — - -- — - -- - — -- <br /> 7 <br /> 8 - <br /> -9- - - ---- ------ -=-- - - --- --- �/ -- <br /> 10 <br /> - <br /> 12 - <br /> 13 <br /> -14 -- <br /> �/ / D —-55323881 <br /> 15 -- � -- - - - -- — --- -- --- — <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 /i M/ <br /> Drivers Signature: of� f Customer Signature: i' ,�� Date: <br /> Drivers Name(print) (/�� J Customer Name(print) <br /> 1 certify that under penalty of porjury under the laws of the Slate of Celilprnra that the mformanon I cern fy that under penalty of paqury ws under the laof Qie State of California that the allormation <br /> provided above is We and affect In addition,I am aware that faWrtoahon of this Ufonnaban may provided above is true and correct In addition,I an'tva�are that falsification of this information may <br /> result+n suspension,revorabon,or deme)of renewal of the Waste Tire Heular Registration pureuant result a+d penalties up W 525A00 per day,per violatbn or admimstralive penalties up b$5,000 <br /> to the Public Resource Code secaon 42960 and may result to civil penalties up to 525.000 par day, per wolsbon per day as described n Public Resource Code section 42862. <br /> per�rolabon or admuhstraavii penallies up to$5.000 per viotetion per day as described in Public <br /> Resource Code section 42962 <br /> payT [ ]Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ )Government <br /> [ ]LEA Exempt <br /> City State: [ ]Agricultural <br /> [ ]Common Carrier <br />