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WORK ORDER/MANIFEST <br /> O <br /> — 1274877— rs + <br /> Waste Tire Haul _r Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: l?'),I'�,� `� �f. <br /> / > . <br /> 1407 Lone Palm Ave. Address: %� yt� /.tet•'� /// <br /> Modesto, CA 95351 City '�`,nrlj@ <f-T Sta e: � ; <br /> 209-521-6221 Zip: <br /> (�✓ �&;7 Phone �� ' <br /> f <br /> /TPID- 74877-01 TPID with Suffix: 45 <br /> j ✓�f' �-/i� <br /> Load Date: ' / Load Type j Whole [ ]Cubic Yard [ j•T rl [ ]Pound <br /> Decal # Pick-up Count: <br /> Licens> # ''c�. f% State: ' Dot Code: RWDY [ Delivery Count: <br /> SIZE MFG. D_Of# TREAD -WH EL COMMENTS <br /> 2 _ -- - -�l r--- Lei ---'-- - <br /> 3 l(r <br /> 4 <br /> 5. .. DIIIIIIIIIIIIIIIIIIIIIIII C4 -3852 ' <br /> .� ,.� - .. - -- - - __ _ __ . IIIIIIIIIIIIIIH11111111 <br /> 7 /�- - - 2_1- - - -- - III II IIII III I1111111II II -- D 55323853 -- <br /> 8 D 55323854 _ III 1111111111111111111111 - <br /> -^ �� - _ IIIIIIIIIIIIIIIIIIIIIIII - D 55323855 <br /> 10 D 55323856 <br /> - _ <br /> D 55323857 <br /> 12 - <br /> 13 --- <br /> 14 - <br /> 15 <br /> . 16 <br /> 17 <br /> 19 <br /> 20 -- - <br /> Drivers Signature: r!. ^/ �` <br /> z• .f` : / Customer Signature: } a f { Date: <br /> 9 <br /> Drivers Name(wal I i��(� Customer Name(print) 4 e- <br /> I candy Ihet under penal of ba undo a laws of the State of(bldpmL9 that the mbrmeuon I ceroly that under penalty of perjury under the laras of the Stale of CalNomia that the information <br /> providaA above is.lru.a co t In addNdn,1 am aware that falmhcauon or tms owmaton may provided abo+e is Wa and correct In addit—,l am aware that falsi6cabon of thrs,nrormatwn may <br /> esu in summisson.ry N. <br /> to denial of renewal of the Waste.Tire Hauler fa <br /> pursuant result unl.penahies up to$25,000 par day per vuuation or admmistraUrn penaleus up l0 55,000 <br /> lot <br /> Pubhe Resource Code se 42960 and ma result rn ra.penalbes up,0325,000 per day, per violation per day as described in Public Resource Code section 42962 <br /> per violation or edministrawe pesWlues up to$5 000 per wnlahon per day as descnbed in Public <br /> Resource Code section 42962 <br /> o,�CData [ ] Imported Load [ ]Exported Load and Location Hauler Exemption Status- <br /> Address: <br /> tatus• <br /> 14 �^ Address [ ]Government <br /> LEA Exempt <br /> City If. State: [ j Agricultural <br /> Common Carrier <br />