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WORK ORDER/MANIFEST <br /> 1274877- <br /> Wast - Tir Ha ,IPr <br /> '� YY�te Tir r � r• . <br /> McCoy Truck Tire Service Center, Inc. <br /> Name: l <br /> � `'i,i <br /> 1407 Lone Palm Ave. Address: A. <br /> Modesto, CA 95351 City: F'' <br /> 209-521-6221 State: ; <br /> Zip: '-�`;�: �� I <br /> Phone: <br /> TPID-1274877-01 <br /> TPID with Suffix: I <br /> Load Date: Load Type: [J Whole <br /> Decal ## [ ]Cubic Yard [ ]Ton ( ] Pound <br /> License #: [']Pick-up Count: _ <br /> State: Dot Code: R W DY —'— — — — <br /> SIZE DOIDelivery Count:_ <br /> MFG. T# _ <br /> MFG. _ TREAD WHEEL — — <br /> 1 5/ I1, 1 Q�] — -- — COMMENTS <br /> - -- <br /> 4 c Z l <br /> 9 --— - --- -----—----- <br /> 10 -- <br /> 11 — <br /> 12--------------- ------- <br /> 13 -- ------ ---_-- ------- <br /> 14 <br /> 15 _ ----- - <br /> :1.6 - ------ -- —___—__ -- <br /> 17 -- --_ —-- — - - --- ----- -- <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature- �� t rl» <br /> Date: 1 Customer Signature: '. <br /> Drivers Name(print) Date: <br /> 9 cer;ty that under penalty o(perjury under the laws of the State o/Catifomia that the irtlormaUon Customer Name(print) <br /> ;x�erded above is true and correct In addition,I am aware that lals(flcation o!this infonnetion ma I certify that under ' <br /> casz;et m suspensan,revocation,or den(al of renewal of the Waste Tire Hauler Re istration penalty of u <br /> Pert ry under the laws of the Slata o!Cal,lornia that the information <br /> 4 Public Resource Coda section 42960 end mey result in civil g y Provided above is True and coned In addltion,I am aware that falsification o/I',s <br /> oer violation or administrative penalties up to 55,000 Penahies up to 525,000 Pursuant result civil penalties up to i$25..'0 0 par day, information mey <br /> Resource Cade section q Par vbletlon pet�Y, <br /> Per vlda0on er da as described in Public Per <br /> �ministrative penalties up to E6,000 <br /> 2962. Dar day as described in Public P y Code section 42962. <br /> c���Data T^ [ ] mported Load <br /> I [ ]Exported Load and Location <br /> Address: Hauler Exemption Status: <br /> [ ]Government <br /> City State: [ ]LEA Exempt <br /> [ ]Agricultural <br /> [ j Common Carrier <br /> JAN-09-2013 12 -r r'"*^9— <br />