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WORK ORDER/ MANIFEST <br /> 1274877- 17900 <br /> 0 <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 [ ] Cubic Yard [ ] Ton [ ] Pound <br /> Decal # _ - — — — [ ] Pick-up Count: — — - — — <br /> License #: IState: Dot Code. RWDY [ ] Delivery Count: — — — - — <br /> SIZE MFG. DOT # TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <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 /> Icertify that under penalty of perjury under the laws of the State of California that the information I certify that under penalty of perjury under the laws of the State of California that the information <br /> provided above is true and correct.In addition,!am aware that falsification of this information may provided above is true and correct.In addition,I am aware that falsification of this information may <br /> result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 <br /> to Public Resource Code section 42960 and may result in civil penalties up to$25,000 per day,per per violation per day as described in Public Resource Code section 42962. <br /> violation or administrative penalties up to$5,000 per violation per day as described in Public <br /> Resource Code section 42962. , <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> �o1.0 DatQ�$ Address: [ ] Government <br /> yM [ ] LEA Exempt <br /> w - m City: State: [ ] Agricultural <br /> • [ ] Common Carrier <br />