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WORK ORDER/MANIFEST <br /> , 12748.77- 3 0:S- <br /> a: <br /> Waste "ire IHa Lifer Waste Tire-Generator <br /> McCoy Truck Tire,Service Center, Inc. Name: .5 tZ-{l'W WC--- S <br /> 1407 Lone Palm Ave. Address: '�,'� '� a 11'1�)V 11i"(1�4j <br /> Modesto, CA 95351 City: PAwt- �scAl State; C„� <br /> 209-521-6221 Zip: '(�' Phone: ; :r "� <br /> TPID-1274-877=01 TPID with Suffix .li'LI <br /> Load Date: 1 1�,' Load Type: [�] Whole [ ] Cubic Yard [ ]Ton [ ] Pound <br /> Decal ° Pick--up-Count:-_ <br /> License #k�.� '� StateC-P% Dot Code: RWDY [ ] Delivery Count: _ . <br /> SIZE MFG. DOT # TREAD WHEEL COMMENTS <br /> r <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 /> 19 <br /> 20. r <br /> Drivers Signature~'J,*b - �- :� Date:l l,l9 , Customer Signature: <br /> Drivers Name (prtgt) _;jc.� r�►— C. !�i Customer Name (print) j <br /> I cardly Iwl undor peal or puqury unaor Ino law.,0l Ilio EIUIe of Celllornla Ilial Ilia Inlorm"'tion I Uunorarlity Ilul ponally or periury un ar Iho owo of 1110$late of CullfundLidhA <br /> ul 1 a nlonawI1 <br /> proalduU arwv.is uua and correct.In addllbn,I tun uwara that lakitla:uion of thdc iniomlatlon my Fuavlllod above la Irua Lind corrocl.In addldon,I mu aware diol IulsilicalloG'01 Ihlo hilunuEaimV,11wV <br /> ne uh in=ponslan,Yewvualivu,or aunlul at mnowW oI IrP Moto The haulor Rauk3radon pur7aenl iwiLill in dvil punwlloo up le&25,0611 par day,Par vwlaw Of aCanlNDlralivd paruiltWs up Io ifil',UU0 <br /> to P50110 Fvurwurau Cc&rodtlon 42960 and nwy wuuh In 6A prutuWua up to$iu,aoo bar day,Pur par violation put Jay as ducorrow In Publlc RedUUn:a Cute euclian 42752 <br /> vtak>tion or adminl-irQUve pbnoldau up to 0,x00 por violation por pay as 0100 ad Iii Public <br /> Ha,niYr'1+rAda auution 429G2. <br /> NO natQ <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> tioSv 1;h ( ) Government <br /> [ ] LEA Exempt <br /> City; r State' f 1 Agricultural <br />