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V - O <br /> � ' �• WORK ORDER/MANIFEST <br /> 1274877- 7 9 5 <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: [ ]Whole [ ] Cubic Yard [ ]Ton [ ] Pound <br /> Decal # - _ ___ [ ]Pick-up Count: <br /> License#: State: Dot Code: RWDY [ ]Delivery Count:_ <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 _ <br /> 8 / <br /> 9 <br /> 10 �J <br /> 11 <br /> 12 <br /> 13 <br /> 14 1 \ <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature: Date: Customer Signature: ,Date: <br /> Drivers Name (print) Customer Name (print) <br /> I certify that under penalty of perjury under the laws of the Stale of California that the information I certify that under penally of perjury under the laws of the Slate of California that the Information <br /> provided above is true and correct.In addition,I am aware that falsification of this information 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 Registration pursuant result civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 <br /> to the Public Resource 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 section 42962. <br /> [ ] <br /> c Derry rImported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> �6rtife, <br /> Address: ( ] Government <br /> 2 ti ( ] LEA Exempt <br /> City State: [ ]Agricultural <br /> [ ] Common Carrier <br />