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WORK ORDER/ MANIFEST <br /> w <br /> I�r _-...„ 222,2_. _: :. ... _. <br /> I 12.74.877- 313 <br /> Waste:Tire Mauler Waste Tim.Generator . <br /> McCoy Truck Tire SarVice�Center, Inc. Name: Z Y.,` `r49,:t, <br /> 1407 Lone Palm.'Ave. Address: <br /> State: <br /> Modesto, CA 95351 City:]�S�F�y` .: <br /> 209-521-6221 Zip: `�' ��`-�� Phone; <br /> TPID-12748.77-0.1 1TPID with Suffix 'i4 <br /> Load Dater;l'�_j ,dal Load Type: [,] Whole [ ] Cubic Yard [ ] Ton [ ] Pound <br /> Decal # \: �� _ o.. .. I C41 .Pick'up Count: — — — — - — -- <br /> LicenseStateq pot Code: RANDY [ ] Delivery Count: <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <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$ <br /> 19 rw <br /> 20 ,. c ] I l I 5 ` <br /> Drivers Signature.;,., fr '. ' �"" Dat6'� -'r''y Customer Signature:,.' 1 ,''_ . ~ Date:. <br /> Drivers Name (�trint) l C r ' Customer Name (print) <br /> ceruty 11'6I under'pwalty of pu,ury uridor IN low*of tho 51alo of CPIltorn o that the Informationou ly If undor penally of perjury miler flits Iowa of Lhe SUld al Cull orn u 1 a1 1ho Inloi Ion <br /> praddad ubow Ic truu Lino corfoci,In 0duluan,I mu dwal'd lhAl Idiblllceflotl of lhid Iufomrtulon may ,pr'ovlded above Ic Wts mrd uorrucl.In aadidon,I om owaro that fal.ufcallon of tivu Irdunndflar uruy <br /> r=ult In:Wori61on,iew000dun,at ddnial of rurwwul of am Wautu Vru I-luufar Nuelo mOn purmuul rduufl iu dAl ponalllau up to M5,000 per duy,per viulnllun Lir dth'runlduallvd panmuuu up to$U,JaO <br /> 1%)puulic Fdsuwce Coda saotroi 1 oho and Otey w6a Gi civil peiLawtiz up'to 525,000 por day,put por violation poi Jay ab ddraxiLad in public R,xmu_rou Coao suction 412062. <br /> viololton or JOnllnblram perl6lllea up to S15,00 ptsr vloltslleri'per day Liu ddscrlhud N PUDUo <br /> Reeuurcd Cude auclluu 40:1U2. <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> �o�`c Data�f Address: [ ] Government <br /> [ ] LEA Exempt <br /> CD <br /> w .► m nity' State: 1 1 Aoricultural <br />