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WORK ORDER/ MANIFEST <br /> I�ill�r. 3 ..6 2.7 <br /> Waste Tire Hauler Waste Tire .Generator <br /> McCoy 7ryck;7ire Service Center, Inc. Name; r �'�� �' `;� 5 r1 aN tS '!� L <br /> 1407 Lone Palin Ave. Address- _ 17 V__ <br /> Modesto, CA 95351 `77 r\ Stale: <br /> 209-521-6221 Zip: Phone: �► , ��s"a?Ll _,2-0 I l <br /> TPIq-1274877r01 TPI D.with Suffix E ��. f t7? <br /> Load Date:3:1 1 1 Load Type:. rte.] Whole [ ] Cubic Yard [ ]'Ton [ ]'Pound <br /> v � <br /> Decal .# _ - ] Pick-up Count: — <br /> License I state CJk Dot Code: RWDY [ '] Delivery Count: .T — — — — - — — <br /> 'SIZE MFG, DOT # TREAD WHEEL COMMENTS <br /> L <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 /> �1 <br /> 20 r m <br /> Drivers Signature:, � �- ''. Date? Customer Signature:f/( --r- <br /> Drivers Name (pr nt) -„)��77—T ' "� C,. C�'�-i'' Customer Name (print) ��t -Jzl_j U <br /> I oarllly Thai un or pons ly of per{Wy taidur IN M.o u Stara d Celllomla 11131 ba IhIOIIId711a11 I uarllly Ilial uaJur perwity of uddury unuei it wwv of VIo'BIpw o C or a ilwt Ina Inlarmuilon <br /> vmvlddd uhuva Id trud ural Comas.In uddlllon,I dill wward pial IaI wailon of IN%Informurtan may providad uaavo 6 truo and CoIrCel.In uod lion,1 otI uwurd ILd1 lalalllwllori 01 Ir,w InlornmlWn moy <br /> rusua In zv+onslon,ravodglon,or donlul at ronutv:d al IIw Wank Tic Haulor 190018lradan pWtlaahl rudull Yt Civil pdnalddd up lu$25.000 Nur rluy,par vlo4tlan or adminlsrrutivu purtulliuc up to$6,1.10 <br /> lu Pufdlu rhdaum'ed Cone§erAlou 4AN dill uldy,esull In civil punolllus up In 520,uou put duy,put par violation pot auy ac daaarlouu in Humid Hauouma Cudd awAurl 42852, <br /> vldoilon or adminlmrative ponoldoo up Io$5,000 par violl"Drl pdr udy so CaBcirwoo In FUAC <br /> Aadvurco Cufla i,nglnn 42967. <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> �os.'�DfYta Tr Address: [ ] Government <br /> [ ] LEA Exempt <br /> City: State: f 1 Agricultural <br />