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K�ORDER/ FEST <br /> W R MANI <br /> Wa9te Tire Hauler Waste Tire:Generator <br /> McCoy Truck Tire Service Center,.Inc. Name: Z 17L:�'�'= <br /> 1407 Lone Palm.Ave. Address: <br /> Modesto, CA 95351 City--N-A-V, �A State:C� <br /> .209r521-6221 Zip: ci T; <br /> Phone:! `; D t <br /> 7PIi:?-1274877-01 TPID with suffix. 1 Y <br /> Load Date:1 ., Load T <br /> ype: ;IQ] Whole j ]-Cubic Yard [jTon [ ] Pound <br /> .Pick-,up Count: ._ — <br /> License #�5� > State QA Dot Code: RWDY [ :] Delivery Count: <br /> SIZE MFG. DOT # TREAD WHEEL '.COMMENTS <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 /> 18 <br /> . 20 <br /> 19 <br /> 11 A C), <br /> Drivers Signature- C- Date pl ( 1 Customer Signature.. _1k- --r 1. --- Date: <br /> Drivers Name (p.0t) G ` btu`- Customer Name (print) <br /> I coolly Visit ur ar penally rf poijuly wider Ihu Iawc al t la stup of C Irorila MI Ina Inlormpl n I cat'Illy Thal undur panalty of poqury uiidar din•uwc of Ilia '1010 of Co 1101111 that Iliainwill.WD11 <br /> uruvidud Jaow,1:i Irw and wrrecf.In Looldon,I am awaie ilial Ialsklkudou ul iniu Inlom141I0ii Ilmy pmidod ubovu Is Iruu mid carat.In uodlllon,I Lill uwura llmt lulellicnilm of till*inlorlllatlrul wuy <br /> IL51.111 1h Euapanulun,revo=worl,or denial of rmwwal of thu Wuctu Tlro l-loulor FiaUlstrallan puruuynl remelt h-ulvll Imndilin.up 10$25,000 per Jay,par violawn or udmlrY:ItGave polluideu up to%,u0u <br /> w Public Fluuourcu Oodo aecii6i 4a8cu and may 1054.11 In Civil tionalUaa up lu:ll�,L,Uuo por day,per pul vlolctdon per day Lu uuacrlbud m pua0c HaoLurau Cudu uuulluu 42iM. <br /> violation or adminiauauvu pananim up to 55,000 par violation par duy uu dusonood In Public <br /> I#Wuuitu Codu sucoari a_ae^, <br /> I ] imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> ;oo`c Datq�� Address: <br /> [ ] Government <br /> [ <br /> ILEA Exempt <br /> m City: state: 1 1 Auiiculturril <br />