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" 7 <br /> j��� t r• ® WORK ORDER/MANIFEST <br /> 1274877- 50849& <br /> Waste Tire Hauler Waste Tire Generator <br /> T "t!1 McCoy Truck Tire Service Center, Inc. Name: <br /> Address:1407 Lone Palm Ave. f l <br /> Modesto, CA 95351 City: ) y�. State:' r-;k <br /> 209-521-6221 Zip: Phone: C <br /> TPID-1274877-01 TPID with Suffix: I ;.�' C(C LI i <br /> Load Date: Load Type: [ )Whole [ ]Cubic Yard [ ]Ton [ )Pound <br /> Decal # - ____ <br /> [ ]Pick-up Count: <br /> License#: I State: I Dot Code: RWDY <br /> [ )REGULAR TIME ( ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. I.'3fl VEHICLE MAKE MILEAGE VEHICLE NO.'-A.1 Ll Lj(,/j <br /> LOCATION: f V r __j J.1-; <br /> 4 <br /> WORK PERFORMED: <br /> _ MILEAGE IN <br /> L MILEAGE OUT T <br /> TOTAL11 ,fCI <br /> R <br /> TIME IN <br /> TIME OUT ) CC A , '_. i <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS ' <br /> 1 <br /> 4 r <br /> 5 <br /> 6 <br /> 7 <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DAYS <br /> Drivers Signature: per_./;'` A Date: - Customer Signature: Date. <br /> li r <br /> Drivers Name(print) --' '. J.4, ,7. . =) Customer Name(print) <br /> I cemty that under penalty of perjury under the laws of t�e State of Calflomia that the information I candy that under penalty of peryury under the laws of the State of California that the information <br /> provided above is true and correct,In addibon,I amewaaware Thal 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 renl of the Waste Tire Hauler Registration pursuant result civil penalties up to$25,000 per day.per violation or administrative penalties up to S5.Ooo <br /> to the Public Resource Code section 42960 and may result in civil penalties up to$25,000 per day, per violation per day as described in Public Resource Code section 42962 <br /> per violation or administrative penalties up to$5,000 per vrolatlon per day as described in Public <br /> Resource Code section 42962. <br /> Waste Tire Delivery Point <br /> [ ]Delivery Count: _____ Date ;ys ]�. [ ]Same As Hauler <br /> opycDate r7 Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> a 10850 Harlan Rd. 1537 E.Market Sl. <br /> 1274877--- B B French Camp,Ca.95231 Stockton,Ca.95205 <br /> 'R TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br /> 0 <br />