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AIL <br /> WORK ORDER/MANIFEST <br /> 127477 <br /> Waste.Tire Hauler Waste Tire generator' <br /> McCoy Truck Tire Service Center, Inc. Name.- <br /> 1407 <br /> ame:1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: State:C;v <br /> 209=521-6221 Zip: Phone: <br /> TPID71274.87.7=01 TPID with Suffix i- 47' <br /> Load Dater �' Load Type: .Whole [ ] Cubic Yard [ ]Ton ( ] Pound <br /> Decal �';] :hick-up Count: <br /> License # ��� State:_ ' Dot Code: RWDY [ ] Delivery Count: <br /> SIZE MFG. DOT # TREAD WHEEL COMMENT'S <br /> Dr <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 /> 1.8 <br /> 19 <br /> 20 <br /> Drivers Signature;'. ('�J .-- . Date:j vZ�)iC Customer Signature: �, '`����� 'y Date../ ."!, <br /> Drivers Name (prey t) j %�ti_ C_ r N L- — Customer Name (print) <br /> con ty that un or ponally of pGllUry Undnr Owe laws of Ihu SlalO Of CnlllurlJa lhal lhu nlannal'on I cnrilly Ihul un ur ponally of porluiy Ulydur Ulu lawn of thu SIu10 of Cullforn u I lgg.p1101'maIIOn <br /> pr0vldud alluyu In liuu mid conaal.In a=0on,I ung Uwara Inut IUL•lhaallon al p11N Ip10llllallun rrwy prOVIO"aD0y0 Ic lruu and corrpcl.In uddloon,I am awalo II'IAl IUIOIIIC(IIIW Jr Il da Yr onnalan muy <br /> i 211 in wcpunslorl,ruvaoallon.or UGmiW ul rulluwnl of lhu M618 Tllu Haul&Ruglelrullon pureuaril -U(i.,e14 punalllns up to li;.5.000 pui day,pe,vlulI ar adndt-1-6vu ponuldow up l0$.5,000 <br /> w PUNIC;Flt tiaW 00 Coda evuliun 42blUU and may wwll In clvl;punulilu:up Io Q5,900 pei day,pur par vlolollon poi dul,ua duscrll dd in public Hu.aurc i COoa 70011on 4:062, <br /> viuiallon or admin arm vu ponollloe up to$6.000 pur vlolBllOn pui day aB Usearlbud In PublIo <br /> HncnlUd6 CUUB 9FlfUGl'142062. <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> �oryc Dctq Tf Address: [ ] Government <br /> ] LEA Exempt <br /> m <br /> city: State: f 1 Agricultural <br />