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Ir WORK ORDER 1 MANIFEST <br /> 1274877- <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address:. <br /> Modesto,CA 95351 City: State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: ( ]Whole [ J Cubic Yard [ ]Ton [ j Pound <br /> Decal # - [ ]Pick-up Count: <br /> License#: State: Dot Code: RWDY [ ]Delivery Count:_____ <br /> SIZE MFG. DOT# TREAD WHEEL cotvimENTS <br /> 2 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature: '' Date: Customer Signature: Date: <br /> Drivers Name (print) Customer Name (print) <br /> I CBrtffy INA under 13 r bf oT perjiry under the laws of the State d Celdomte Ihel Ih*imbrmalim f xm(y Mal rrMer papally of Niury urew Me laws of the San,of Cahlornia Ihai The Uttorrnation <br /> provided ahora a ling and Carred.In 80ditien,I ern aware that falsrEcamon Of mIi udormalion may provided ebrnle Is true and caput in odditien,I am awa•e MB(fWricalgn of Lia u4brMllon may <br /> reeull'+i auaprnarm,ravo:eUan,or danld d ranawel c!rrrt Vlae9vTia Fteuler Rcybronem prrsuant raaull cM ponalUee up IU S29,CO3 oar dory,per worawn or ajminimrMhe parweae up in Ratio <br /> to MR PWtC ReBoUiCe Cade""bon 42980 and may resull m cnd pena4Ws up to S75 ow per day. per yiolatwn per rLiy as da;uCed In PUAr.Rasouroo Ctde victor 42982- <br /> per <br /> 2982per volatien m admnslr,a"pan alas up to S5,0311,per Midarm per Gay as dascnhed in Pun1c <br /> r.: ourts Code serum E2962. <br /> IV�,DatapF ( J Imported Load [ ]Exported Load and Location Hauler Exemption Status: <br /> Address: [ ]Government <br /> [ ]LEA Exempt <br /> City State: [ I Agricultural <br /> [ ]Common Carrier <br />