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WORK ORDER/ MANIFEST <br /> aofli- 1274877 3 v '6 <br /> - <br /> Waste Tire Hauler 'Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: 'C 4a t -� <br /> 1407 Lone Palm Ave. Address: -t`� � �' ""��"{`' �s��`-" <br /> Modesto, CA,95351 City: '��' 1 ii � State: <br /> 209-521 621 Zip r ��.i J Phone:a' <br /> TPID-1274877-01 TPID with Suffix <br /> Load Date: C.7I Load Type: Whole [ ] Cubic Yard [ ] Ton [ ] Pound <br /> Decal # [Ij Pick-up (Count: — <br /> License 41 <br /> J I ) 5tate:Cg1 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 /> 17 <br /> 18 <br /> 19 <br /> 201 <br /> Drivers Signature ``jG`-- Date:��rt= `�, Customer Signature: / �, t4�°.:�' �-'�t� "G7 . Date: <br /> :"`�-' <br /> Drivers Name (prin ) ,)r� '� ,-! �`�"�� """ Customer Name (print) <br /> I cony thuf un or ponally 01 p01]lliy Undar 1110 law;011h0 91G{0 of Calllorn d that Ulu Infornlailce I C01111y 1101 Older Imnelly of purJury undur Iho Iawu ul dm SUu of Culllomia Thal Ihu Inlormullon <br /> pruridea da0vc Is INu and oorrucl.In udditldn,I Lull awura Iliut fdNr111Cf1IIc4i 01(lila 1111on11ullun nay providud uLnu0 I:IrUO arW C011'yCl,III 00I1,101L I lllll Awaru Incl Ia13111CU1I0n of 013 N11oinaU0111nff)' <br /> mull In:41;F 310 n,fdVOCU110u,uP dyidal 01 rai0401 Ot IN 1VUaW Tim Hwilor HuglaIM1100 Pui4ttwit idaWl lu Clvll pwiulllu:up to$°l:,UW pur cloy,put vlcluilon or adnduiwulivu pwlwlj�up Io$7,000 <br /> to Public rticourca Codu uuotlan 430tA Ona m0y rw:ull N1:lull punalliee up to 225,000 put duy,put pnr vwl,llon pol Oay as iWa Wad Iii PuUIIC FlLDUIL ltu COdO Hdon 42362, <br /> wolrition Oi aOmInIBUuIIVO Iwildlltidu u,,I,fl$,000 uai vlolall011 liar day Oc 4O.C1113Od In P0110 <br /> 9tlGUUIW Cuda(xviUrl d.U6., <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> tia pgtgTr Address: <br /> ( ] Government <br /> u ( ] LEA !Exempt <br /> • m (D City: State: [ J Agricultural <br /> F 1 Common Carrier <br />