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02/20/2013 15: 31 205-521 1 MCCOY TRUCK TIP PAGE 01/01 <br /> ' oil / WORK ORDER/MANIFEST <br /> Qy <br /> 1274877- 4 7 219 <br /> Waste TireHaulllar Wastg Tore Generator <br /> McCoy Truck Tire Service Center, Inc, Name; l onLI`dojcrs <br /> 1407 Lone Palm Ave. Address: *3,0 y 5) M G ,-y <br /> Modesto, CA 95351 City: C-S C a,] n-, State: <br /> DEC a 5 2012 209-521-6221 zip: a 5 3C'LO Phone: <br /> TPID-1274877-01 I TPID with Suffix: 1 3q,3IS 6'j <br /> Load Date: ]`]'1- - Load Type: Whole [ ]Cubic Yard ( ]Ton [ ] Pound <br /> Decal # t . - O C� $ ick-up Counfi: f 9 <br /> License#: CaS State: Dot Code: RWDY ]Delivery Count: _ <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 Aro Ste. <br /> 4 assl7.)Ras <br /> 5 A4 j/-lot 11's . � <br /> — — .._.............. <br /> ......_._..... -----_.----...... _ <br /> 6 ;X15/1S R Q.s � <br /> 7 la-ALS Ur <br /> a .. <br /> 9 <br /> 14 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 16 <br /> 19 <br /> 20 <br /> Drivers Signature: Date: Customer Signature �_ ;' , r� Dater <br /> Drivers Name(print) Customer Names(print) r-It r <br /> Ionrtify that unbar pPannlry of par]ury and r the lawn 'Ihn State of Callfomin that the Infomnnilon 1 aemify that undor penalty of parlury undartho laws of the£aorto of Callfornla that thio Information <br /> pmvlC ad above In ffup Ano comad.In Addition,I Am RWafn that fRIA1fICpllan or INA Information may proWdntl above in trun And corrool.'I,addition,I am nwom that fnesetfanteon of this Information may <br /> x961111 Jr.eUBpeflBion,feuoaallon,or oenis of renewal o1 IhA W9Are Tire Hauler Ragl�amAlMn purAuant malat rlvll panPII up to$75,(708{gar&R.,Rar vealpt{on or Adm INAI/AtIvp ppnaetlAn up to S5,I100 <br /> to the Public Resource Code eacilon 42980 and may result In chil denslllee up to S 5.000 user d8y. per ufolallon per day as rlewiheti In Pub r- "ourc9 CM9 Section 42982, <br /> ear violation or adminlstrmlwpanoltloo up to 36,001 por vlolatlen par day ac doocrlbed In Public <br /> r/RAO11rCA COap ARC110n 42% <br /> ro oaf <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemptlon Status: <br /> Address: [ ]Government <br /> [ ]LEA Exempt <br /> City State: [ ]Agricultural <br /> - [ ]Common Carrier <br />