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NOV/17/2015/TUE 09: 51 AIS JSG cking FAX No, 209-36Q-0$79 P, 003 <br /> ( WORK ORDER/MANIFEST <br /> 1274877-5 0 4 Q 1 7q <br /> V Waste Tire Hauler <br /> Waste Tire Generator <br /> McCoy Truck Tire Secy],ce Center, IQ_Pll T l <br /> 1407 Lone Palm ACTe. r ✓ Address: I q t+0 0 N o r��n N <br /> Mcddesto,CAD635 ? Ity: i4State: L� <br /> 209-521-62 1 ,i ._.� 5 L I <br /> TPID-127487' -0 Z Phone: <br /> i TPID with Suffix; t 3Sul <br /> Load Date: Load Type; Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # [ 5 _ v 2 <br /> Wick-up Count: <br /> License#: r I!b)c - RWDY 3 State: C� Dot Code: —— <br /> t <br /> REGU!AR TIME [ ] OVERTIME [ ] CALL OUT CUSTOMER PO# <br /> r <br /> FLAT EPAIRS WHEEL SWITCHES MT/DIS T y,,,illA L f G1 A0 Qti VZ 71r l �/1 <br /> LIENSE N0 VEHICLE MAKE MILEAGE N,A VEHICLE NO. <br /> hOCATION: USF {<.i�.,•.r'•C t21 t', t nur�- ,nI <br /> 1�1 err.. <br /> WORK PERFORMED: _ MILEAGE IN <br /> L l� ry MILEAGE OUT (I 7 I <br /> M. TOTAL <br /> TIME IN <br /> TIME OUT 3"147? <br /> ti• <br /> SIZE MFG. DOT# TREAD WHEEL, _ COMMENTS <br /> 3 <br /> 4 <br /> — 03 �v <br /> 5 I r;�il <br /> 6 �I� �:1 7 I,J �►� h�. � <br /> 7 <br /> B <br /> briversSignature: t �- Date;Iv •2f_�' Customor Signature:... ',`.•c. :' Date: <br /> Drivers Name(print) Av1f,,,t A ,„_ Customer Name (print) <br /> arti Ihel Under na! of oar u - <br /> fY % ty 1�Y under the lawg 0(the Stale Gal00mlfi That the infirmBllon 1 cartry 11111 under p,,,a of pa, unbar the laws of the alal6 of California that the Infonnatlen <br /> provioad above is true an0 eOrrecl.to addMon,I em aware that releifiadon of thla IgtO�nation may provided abovq 18 Ince and[Orrell•In addition,I am aware that fel-ilic,atlon or this interrnatlon may <br /> raeUll In evepenslon,rovocation,or denial of rantrwal Or the Waste Tina 11 War Re jg!llon pUr5U5nl r¢sult Clvll penaltia;U l0 325,DDD er da <br /> tot Pubrc Rasowcq Code aecL'an 0�96o end r,-•/resvl!In civil penalties up l0 S7S,DD0 per day. D p y zrvlolalian or aCminlelr911ve panalUea up 10 39,6o0 <br /> pper vloleticr r administrativ¢ppanelQee up to S%ood per vbletion par pay ea deccribaa In PUDpc y per violation per day as dasrnlpatl Itt public ResourCB Code section 12962, <br /> Regol. de eecllon 42862. <br /> [ Delivery Count: —` Date ►._> Waste Tire Delivery Point <br /> [ ]Same As Hauler <br /> o��c°efo "Iasfe Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST [ McCoy TrUCk Tire Service Center ( ]McCoy Truck Tire Service Center <br /> 274877-504017B 10850 Harlan Rd. 1537 E.Market St, <br /> French Camp,Ca.95231 Stookton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br /> Received Tlme Nov, 17. 2015 10:.0..8.AM No, 1421 <br /> z <br />