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® WORK ORDER/MANIFEST <br /> 1274877-60574 A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name::_Te` _I` 9 <br /> 1407 Lone Palm Ave. Address( S � C i }C A V e- <br /> Modesto, CA 95351 City: r j,, G State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: , Ll <br /> Load Date: / & Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # - - c ____ <br /> —— ( ]Pick-up Count: <br /> License#: I. � -J I State: I Dot Code: RWDY <br /> [ ]REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> � <br /> LICENSE NO. JJ VEHICLE MAKE MILEAGE �`7?1 t-I 1' 7, <br /> L VEHICLE NO. `.,�• � <br /> LOCATION: t.A i I t d T Y \ /C.4 / (4 _v 11 1 u_ C_ JV <br /> t <br /> WORK PERFORMED: MILEAGE IN <br /> IZ—o gVI" 1�. w� j j�k ✓� r(L6,i MILEAGE OUT L+ `x_77 7 <br /> !R /✓, f - <br /> 4 1 . Y-'� cc 1; - - --- TOTAL_ <br /> if J• r — — - - <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 - ,J <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: f �f /� ;Pate: !—/ Customer Signature: Date: <br /> r <br /> Drivers Name(print) l�� `"f7 7 7 -'.1' Customer Name(print) <br /> I certify that under penalty of perjury under the laws of the Slate of California that the information I certify that under penalty of penury under the laws of the State of California that the information <br /> provided above is two and correct.In addition,I am aware that falsification of this information may provided above is true and correct.In addition,I am aware that falsification of this infonnabon may <br /> result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant result civil penalties up to$25,000 per day,per violation or administrabve penalties up to$5,000 <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 violation per day as described in Public <br /> Resource Code section 42962 <br /> Waste Tire Delivery Point <br /> [ ]Delivery Count: __—__ Date i / �_ ( ]Same As Hauler <br /> a�oar,r� Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST �s° �2 ( ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E.Market St. <br /> 1274877-*U ;;� 1 4 1 B French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />