Laserfiche WebLink
C — WORK ORDER t MANIFEST <br /> 1274877- � �•�'� �' <br /> Waste Tirg Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name; '�•• lti. I.;. �t`,,s_, _ v' - <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: V"�' '''rV r State: <br /> 209-521-6221 Zip: Phone: .. " t •. _. <br /> l'PID-1274877-01 TPID with Suffix: <br /> Load Date: ! I Load Type; `[w]Whole ( ]Cubic Yard [ J Ton [ ]Pound <br /> Decal # '�, .�; [;;]Pick-up Count: <br /> License#:?...' ` � . : G,,`i 5tate:4.,1^; Dot code: RWDY [ ]DeliVM Count:—_— <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 - -- ———..... ....... ..,.. ._. _-�- _... ............. -- <br /> 3 <br /> 5 <br /> 6 <br /> 7 + <br /> 10 --._.... ....._.._ <br /> 12 - <br /> 13 _..... ._- ...._...._—. --- <br /> 14 <br /> 15 -- .. -- ------ <br /> 17 --- --..... . - ---- -- - <br /> 19 _._-_... - .._.. .. ........ <br /> 20 <br /> Drivers Signature:)" - r ,,• Dated Customer Signature: ( - r' Date: <br /> Drivers Name (print) Customer Name(print) <br /> I Corllly ifal under penally or Perjury under IN lows of 1IN Slnle of COUlomw 0101Ihu Information I cantly alai wider penally til peory U dur m Iaws or the Slate or Crrllfu1nia wo the ln(ormatian <br /> pravldud abovo I6 11'uo and 4orwat In addition,I enl award UiU1loL••kulon or lhie InfunneUal reey pfnvloatl apavu is true and oorrecl.In ndwuull,I mil uwGro that lalclrlaallon ar the lnlonna0on umy <br /> rusUi in sue:penaion,revoc illwi,ur denlai or runswad of M1a Weele Tiro Hau'.or N h:Irullan pumuanl reaull uvll pujlelllea Up 10$25,000 pot•as,pof Vlalutim or ed111I11IaLI'U1IVe pe11/1IIlub up l0 55.000 <br /> Ia lP1e Purill Ro:oureo coda pcuon 42690 end may NSUU In oivll pan:ddea up w 525,000{x+1 Uuy, por vloWllon par day as dul:crlbud in Publlc RaeeufCa Cow wcdan 4NO;!. <br /> wr vlaladan or edulhdau'n0re punal0e>Up Io 36,000 per Wulullo+l uui Uoy o:do.edpad In Publle <br /> Iquauunv Co&.ocllon 42W.,. <br /> [ J Irnported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> Address: [ l Government <br /> LEA Exempt <br /> City State: [ ]Agricultural <br /> Common Carrier <br />