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i V WORK ORDER/MANIFEST 1274877- Waste Tire Haute-L Waste Tire Gpnerat L-- McCoy McCoy Truck Tire Service Center, Inc. Name: 1407 Lone Palm Ave. Address: Modesto, CA 95351 City: : State: 209-521-6221 Zip: Phone: TPID-1274877-01 TPID with Suffix: Load Date: Load Type: [ ]Whole [ ] Cubic Yard [ ]Ton [ ] Pound Decal # _ _ - _ [ ]Pick-up Count: License#: I State: Dot Code: RWDY [ ]Delivery Count:__ _ _ _ . __ SIZE MFG. DOT# TREAD WHEEL COMMENTS 2 3 - - - - - - ------ v - 4 LL// - -- — 5 - - �� - — - -. 8 � 9 10 11 --- - _.-- -------- - 12 13 14 \ -- - 15 16 17 18 20 Drivers Signature: Date: Customer Signature: Date: Drivers Name (print) Customer Name (print) I certify that under penally of perjury under the laws of the Slate of California that the Information I cerlity that under penalty of perjury under the laws of the State of California that the information 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 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 adminlslreeve penalties up l0$5,000 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. per violation or administrative penalties up to$5,000 per violation per day as described in Public Resource Code section 42962. [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: Qr`" Address: [ j Government LEA Exempt P City State: ( ]Agricultural [ ]Common Carrier