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Ink <br /> • WORK ORDER / MANIFEST <br /> 1274870 . . <br /> Waste Tire Hauler Waste Tire=Generator <br /> McCoy Truck;Tire.Service:Center, Inc. Name: S C., '�l.y.( ' <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 Clly; Yv'%1, ii State: C`(� <br /> 209-521-6221 Zip: C .: Phone; >,b �;A�, <br /> TPID-1274677-Q1 TP ID with Suffix,I ~J'`\ <br /> Load Date S Load Type: ] Whole [ ] Cubic Yard ( 1 7on. '( ] Pound <br /> Decal # LO - '�?'�-�= `'�. [%.] Pick-up Count: - - — — - — — <br /> License #1-5V;LI\ State: C,� Dot Code: RWDY [ ] Delivery Count: <br /> _ SIZE MFG. DOT # TREAD WHEEL COMMENTS <br /> 1 aur��I•o�\`�:'� � 1 �.U�"�.� VV��C..7` � b.<.��'��•'�''��jr�. <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 /> 19 <br /> 20 <br /> Drivers Signature: t�C\� ' DateCustomer Signature'. j ��/�f (I:W Q1,d.���,��'� Date:_ <br /> Drivers Name (prip4) r v �_ 11A I- Customer Name (print) <br /> oortly Incl undLr oolWly 9:1 pa�uy undor thu I uw:of mu Slulu of Callfonila that Ihu vllormaUor, I Cwtlly 114d uiidur puimlly al pur�xy un ur Irto -wc 0 the Sl4lu o Cq lore 4 I AI Inc Inlormallan <br /> U.0Vidud alcove Ic Irua and eormci In oddiWn.I unl QW410 111a11p1alllcallen of 017 f11l0illlalluo IuaY pruvldutl abavo is lrtlu and corl'ocl In oodlllon,I hnt eiwuit IIIAI IaI::IIICUIIJII of 11'116 illfuioulull may <br /> mnull In cusponsion,ruvocalloll,of duuiul of muwal ul I6u WC610 7oQ Hauler Fluuldlmllurl Pafaaolll ru::ull In civil pi,n(dllo5 Iq)to 9;:5,000 061 day,pui vfulnliuu ui aWululrhalivu pbutlhiva up b bo,UUU <br /> to F011C flo8uuuou Co0u euclicu 4-1,10 and muy ruuult in civil punuliiaG up to�L4,U00 por day,pi out vlululim put day nu daccrtud Ui public Hosodmi Codu uucllon 42062. <br /> vI0 al on or udminlaradvu penalllu:Up to 5,000 pdr vlolallon por day u:rook and in(unu <br /> Rusnurcn Cnoo <br /> u­inn 49P(B2. <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> �o�tic Dafq Address: [ ] Government <br /> u [ ] LEA Exempt <br /> M F City: S'lale: [ ] Agricultural <br />