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O� <br /> WORK ORDER l MANIFEST <br /> 1274877- A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: `1 1_C <;[ r t- 1 <br /> 1407 Lone Palm Ave. Address: - r)S"D, w ' It, <br /> Modesto, CA 95351 City: j (? State: { r" e.",.f, <br /> "", Phone:x cf) U <br /> 1 <br /> 209-521-6221 Zip: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: 111, 2 111 20 I Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal #_ - _ ___ [ ]Pick-up Count: <br /> License#: I State: I Dot Code. RWDY <br /> [ ]REGULAR TIME [ ] OVERTIME [ J 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 /> c t l [ (7 YL ( L MILEAGE OUT <br /> _I"`CJ v U'_� TOTAL <br /> t � r <br /> t• ( 4',r)LtL ff )t rk_cr �Vc <br /> 61 A ( (.I IBJ <br /> TIME IN ~c � Q � <br /> TIME OUT { LJ O r <br /> �j <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> qq . <br /> :>e.- <br /> 2 <br /> 7c- <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: s L Date: Customer Signature: /y.., <br /> Date: r. <br /> _ +► :oma-'^� <br /> Drivers Name(print) J�^ r �� t �^' 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 Inform may provided above is true and correct.In addition, am aware that falsification of this information may <br /> resat in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant result civil penalties up to 525.000 per day.per violation or administrative penalties up to E5,000 <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 /> I� Waste Tire Delivery Point <br /> [ ]Delivery Count: —____ I Date 110 [ j Same As Hauler <br /> amara T Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST �° [ I 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 />