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® O <br /> IV ' ' WORK ORDER/MANIFEST <br /> 1274877- 44 <br /> Waite Tire Hauler o wact�Tire r�enerator <br /> v til [�HS H � ►� U <br /> McCoy Truck Tire Service Center, Inc. Name Vr-••t U� .�� <br /> 1407 Lone Palm Ave. Addre s: I V C <br /> �`~ ' <br /> Modesto, CA 95351 City:^ Stat'! l� <br /> 209-521-6221 Zip:C� Phone/:' <br /> TPID-1274877-01 TPID with Suffix-, <br /> ate �J „ Load Type: [..}*eVT O Cubic Yard [ ]Ton [ ] Pound <br /> s.� 4 [ ]Pick-up Count: _ _ <br /> r� tate: Dot Code: RWDY [ ]Delivery Count:_ <br /> #: 5.� s <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS -. <br /> .aDat�L 4. t ustomer Signature: Date: <br /> . ,J 9 <br /> rs Name(print) l 1 t <br /> Customer Name (print) <br /> hal under penally of perjury under the laws of the State of California that the information 1 cavity that under penalty of perjury under the laws of the Stale of California Net the information <br /> above is true and correct.In adds me,I am aware that falsification of this information may provided above is true and correcl.In addition,I am aware that falsification of this Information may <br /> suspension•revocation,or denial of renewal or the waste Tire Hauler Registration pursuant resuviolat olt civil o perdayasies up tdesc5ibed i000 o Publ per <br /> codeadministrative <br /> s section 4298penalties up l0$5,000 <br /> tDlic Resource Code section 42980 and may result In civil pe.allies <br /> up l0 525,000 per day, per Y <br /> tion or adminiatralive penalties up to 55,000 per violation per day as described in Public <br /> e Code section 42962. <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> Address: [ ] GEA Exempt <br /> City '. <br /> State: `,. [ ]Agricultural <br /> ( ] Common Carrier <br />