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" ® ;1 <br /> WORK ORDER!MANIFEST <br /> 1274877- <br /> y xite Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: n <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: c r'..,, Load Type: ( ]Whole [ j 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 /> 1 <br /> 2 <br /> 3 <br /> 5 <br /> 6 <br /> 7 <br /> 8 - _ <br /> 9 <br /> 10 <br /> t �— -- - <br /> 13 r <br /> 14 <br /> 15 - -- <br /> 16 <br /> 17 _ <br /> 18 <br /> 19 _ <br /> 20 <br /> c . <br /> Drivers Signature: Date: Customer Signature: Date: <br /> Drivers Name (print) Customer Name (pr(nt) <br /> I certify that under penalty of perjury under the laws of the State of California that the information I certify that under penalty of perjury under the laws or the State of California that the Information <br /> Co 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 ponalGes 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 Cade 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 /> ( ] Imported Load [ J Exported Load and Location Hauler Exemption Status: <br /> Address: [ j Government <br /> LEA Exempt <br /> City State: [ ]Agricultural <br /> [ ]Common Carrier <br />