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WORK ORDER/ MANIFEST <br /> 124$77, .3�q <br /> Waste Tire Hauler W'as'te"'Tire,Generaitor"' <br /> McCoy Truck Tire Service'Center,.lnc. `Name: 3` kA r owa-Z L, <br /> 1407 Lone Palm Ave. Address: v �`5�1 '���' <br /> Modesto, CA 95351 - City: d�k �\o State: <br /> 209-521-6221 Zip: ? 1 Phone: t ..aPl- <br /> 1 <br /> TPIDt.127487.7-01 TPID with Suffix t�{'[.•U roZ, `�'1 <br /> Load Date: la �} ��. Load Type: [�J Whole [ ].Cubic Yard [ ]Ton [ ] Pound <br /> Decal # ` �? - I [�-�� .Pick-up Court: — <br /> License#: J.�.��v� State:` Dot Code: RUV.DY [ Delivery Court: <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 /> 12 <br /> 13 <br /> 14 <br /> 15. <br /> 16 <br /> 17 <br /> 18 <br /> 19 A <br /> 20 <br /> Drivers Signatur `�0----. — Date1�;�;/'�= Customer Signature.: <br /> Drivers Name (print) �rL'�_. t �`'�"U —��`�- Customer Name (print) <br /> cunNy thal UN11O1`0a11W1y of pequry undor 1110 Iowa of Ih0 Pdala of Cnliloirlla Ilial Iha InOAnaWn I will;thin u ar pallWly UI DarlUly un ar tht: 'wr al I110 61alo nl Oadloffllb Owl Ilse n ornWlon <br /> pfovidod elwva it Iruu acid coincl,III uW111un,I um uwura 111x1 taLhle�llon of thl:Inla ntallmr way provltlod above Iu . and. . In wdldon,I Favi awufu that faloilimation el thla Inlormadon may <br /> ronult In su.ponJon,iovoc&lbn,or duntut of rom wal of trio Wavle Thw Maulor FWOlnlrelior pursuant fouull In civil punollion up w 025,000 par Joy,bur vloualon or;4dminl0traFlvu lianulliun up w ICa,000 <br /> to F61h;Renuutce Codo:ticilon.12060 and uwy ruauh In civil puaalllus up to;.5,000 pur dray,put por v1010060 Der duy ac&ezrlbaa In PuDllo 19 ourue Cuda uixtion 42SU2. <br /> violatlon or naminblfPdve DWlaldua up to 55,000 por violadon pai day as d0E4riWal In Public ' <br /> Hufnnroe Cuda Wnllon 4'+296:. <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> fic p4tga Address; <br /> �o r [ ] Government <br /> u [ ] LEA Exempt <br /> W -. � fes° City: f 1 Agricultural <br />