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V <br /> WORK ORDER!MANIFEST <br /> 1274877- �` Y <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: J <br /> Modesto, CA 95351 City:.- State:.. ._ <br /> 209-521-6221 Zip:• Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: rf Whole [ ] Cubic Yard [ )Ton O Pound <br /> Fick-u { <br /> Decal # �_ .� _ _ [ 1 p Count: —— =—1 • —— <br /> License#:rr•, State:. J Dot Code: RWDY [ ]Delivery COuit:— —— — — —— <br /> SIZ= MFG. DOT# TREAD WHEEL COMMENTS <br /> - -- - . <br /> 1 , <br /> i � <br /> 2 <br /> 3 ] z <br /> 4 <br /> 5 <br /> 6 <br /> 7 11- <br /> 8 -- - <br /> 9 <br /> 2 <br /> 10 <br /> 12 — - ----- -- <br /> 13 - <br /> 14 <br /> 151 <br /> 16 <br /> 17 - <br /> 18 <br /> i <br /> 20 <br /> Drivers Signature: Date: Customer Signature: Date: <br /> Drivers Name (print) ; Customer Name (print). <br /> I certify that under pr nally of perjury under the laws of the Slate of California that the information I cattily that under penalty of perjury under the laws of the State of Callfomia trial the information <br /> provided above Is true and correct.In addition,I am aware that falsification of this�nlormatlon may provided above is true and correct.In addition,I am aware that falsification of this information may <br /> result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Reyisnation pursuant result civil penalties up to$25,000 per day,per violation or administrative penalties up la$5,000 <br /> to the Public Reaour"M Code section 42960 and may result in civil penalties up to$25,000 per day, per violation per day as described in Public Resource Code section 42962. <br /> per violation or administrative penalties up to$5.000 per violation per day as described In Public <br /> Resource Code sect on 42962. <br /> [ ) Imported Load [ ) Exported Load and Location Hauler Exemption Status: <br /> Address: ( ]Government <br /> ' ( ] LEA Exempt <br /> ` <br /> City ,�-,.: State, Agricultural� ] <br /> [ Common Carrier <br />