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a o� <br /> WORK ORDER I MANIFEST <br /> 1274877- <br /> ,Y <br /> Waste Tire Hader Waste Tire , -nerator <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: L ; Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: [z,14/hole [ ] Cubic Yard [ ]Ton [ ) Pound <br /> Decal # _ - _f [:.]Pick-up Count: - <br /> --= -- I II11 <br /> License #: ",4 'i, (..� State: ,:,, Dot Code: RWDY [ � IIIIIII��I�III���lllliil p III I���I�I�N�I�111I1I1I <br /> SIZE FG. DOT# TREAD WHEEL p <br /> 1 _ - 600v -L10 - flS—_ -' IIIIIIIIIIIIIillllllllll <br /> I� N <br /> r <br /> ., p 41801531 —_ .- III III'III 1 II II IIII III II <br /> 2 ; ;,:li 1.7 V" 1305 ��'�-- _ <br /> . -.�� '_.. :'•.--, D 41801532 --- <br /> 3 `''rte' ' ` --- �J IIIIIIIIIIIIIIIIIIIIIIII <br /> 4 �frj:,a�: >sc_t [..��— _. _.. p 41801533_ 1111111111111NIIIllllll <br /> 41801534 <br /> 5 U0 <br /> ` ( IIIIIIIIII�IIIIIIIIIIIII <br /> 6 `'oj I \ p 41801535 <br /> - -''.� III IIIIIIIIIIIIIIIIIIIII <br /> 41801536 <br /> 9 3P <br /> D 41801537` <br /> 10 :� : n�T � S f IIIIIII�II11111111I111111 <br /> 1801538 <br /> f' 2��� -�,- -_- � 11111111111111111111111 � <br /> 1 .• .•�-� � --- _ � � ------ _ 0 41801530 _. <br /> 13z c�L�1 _-- ----- IIIIIIIIIIIIIII1VUI II <br /> D a 1801., <br /> 14 <br /> p 41801540' _ <br /> 15 <br /> 1617 <br /> - — -- <br /> - -- - <br /> 18 <br /> 19 <br /> 20 <br /> Date: <br /> Drivers Signature: �' f~e Date: ! Customer Signature: r•, <br /> Drivers Name (print)•I i L` l a M ' Customer Name(print) ,'r� r.J in <br /> rr.k�a Information <br /> 1 certify that under penalty of perjury under the laws of the State of California Ihat the information 1 C�d d�abo e s Iat under Due anGocorre�ct In additlon.l1 am aware sthalt fa sificat on ofl(histInformation may <br /> provided above is true and rronacl.In addition,I am aware that lalsifiplion of flus inlorma0o^may Pro r da per violation or administrative pe^allies up to$5,000 <br /> result in wspensbn,revocalan,a denial of renewal OI the Wasta Tire Hauler ReeggfiistraUon pursuant result civA penalties up to$25,000 pe y.p <br /> to the in c Resource Code seG on 42960 and may resv o'e1�lce ay as up <br /> eto sc$25, D cay' per v Olaf on per day as described in Public Resource Code sect on 42962 <br /> per vtolat—or administrative penalties up to$5,000 per <br /> Resource ribeK <br /> Code seClion 42962. <br /> [ I <br /> Imported Load [ J Exported Load and Location Hauler Exemption tatus: <br /> ress: J Government <br /> A <br /> LEA Exempt <br /> [ )Agricultural <br /> City State: <br /> ( ] Common Carrier <br />