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t ® WORK ORDER/MANIFEST <br /> 1274877- 7 0 6 5 3 9A <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: i r Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal <br /> — — ———— [ ]Pick-up Count: <br /> License#: State: I Dot Code: RWDY <br /> [ ]REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. VEHICLE MAKE MILEAGE VEHICLE NO. <br /> LOCATION: <br /> WORK PERFORMED. MILEAGE IN <br /> MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <br /> 4 <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: Date: Customer Signature: Date: <br /> Drivers Name(print) Customer Name(print) <br /> I certify 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,I am aware that falsification of this information may provided above is two and correct.In addition,I am aware that falsification of this information may <br /> result,n suspension.,revocation,or denial of renewal of the WasteTire Hauler Registration pursuant result civil penalties up to$25.000 per day,per violation or administrative penalties up to S5.000 <br /> to the Public Resource Code section 42960 and may result in civil penalties up to 525,000 per day. per violation per day as described m Public Resource Code section 42962 <br /> per violation or administrative penalties up to$5.000 per violation per day as described in Public <br /> Resource Code section 42962 <br /> [ Delive Count: Date Waste Tire Delivery Point <br /> ry ————— [ ]Same As Hauler <br /> �,c Dara�^ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST ic° a [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E.Market St. <br /> 1274877- B French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />