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09/29/2015 14:31 20952_ dl MCCOY TRUCK TIF PAGE 02/03 <br /> WORK ORDER 1 MANIFEST <br /> I il� <br /> - _ 0 1274877- 7 3 381 <br /> Waste Tire Hauler WaStp Tirn Generator <br /> McCoy Truck Tire Service Center, Inc. Name <br /> rr��cc��CC11 tio'� �� <br /> 1407 Lone Palm Ave Address: <br /> /Modesto.CA 95351 City G1� State: <br /> OC lrT Z 8 Z014 209.521.6221 Zip: Phone- <br /> TPIp-1274877-01 I TPID with Suffix: <br /> Load Datc:j — �, Load Type" I Whole I I Cubic Yard L j Ton Pound <br /> Decal#_� L-[' - U DqPick•up count: <br /> License Lc�� State Ga Dot Code: RWDY [ ]Delivery count: <br /> Xl REGULAR TIME [ I OVERTIME [ ]CALL OUT CUSTOMER PON <br /> FLAT REPAIRS WWH�EEL SWITCHES MT/DIHSMCT l l <br /> r_1LICENSE NO.[WdA)Of)` 9"VEHICLE MAKEt " MILEAGE VEHICLE NO. y, b <br /> t� <br /> LOCATION. ,"Jv— '`U <br /> WORK PERFORMED0 <br /> Le,4a•s �—cior .. MILEAGE IN <br /> '�iSvvlvi� J 1 r y1n�3y MILEAGE OUT <br /> TOTAL <br /> -- TIME IN - <br /> TIME OUT <br /> SIZE MFG DOT# TREAD WHEEL COMMENTS <br /> u�a�-•S" � �V t�iC (� _. <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 _789 <br /> Drivers SI nature: G 0'-7 Dai G Customer Signature; Date: <br /> Drivers Name(print) Customer Name(print) <br /> I:endv+n1.nWr p•n•'iy C1 oe•Iury N`dor Inn nwv N inn elalo of CoY,lornln In•n��I�IMrovdo+ cah N n•1 ant!•dire Iv of Oegvry uM•N�'•w►01 pip Slolo or Cnldornu InPI IM+brtne•lon <br /> Nvvm�d rh0a0,e vus and cclmn.1!eA(IrlOn, �m awa•niha •inl;r!'bn oth S L rormauon m.y pdvldid rtdvn I•cn,n anq 111 l(1 In pddlllon,I am•vara m•I I•yNLation oltM•In'CIm•Ibn m•y <br /> n•.Il In y;ppnriGn, •VOUUn�,nr A•nn:pf Ip+pµN pl In•W•I.T'..M•if pl NCCI•trnnpn�„i!�I�,.� •06u't ciw Lnno•a•♦.IP Ip tz$000 opt doV.Cdr NUI•Ilaa M ltlnHM1llbnllvo DonolllU•LP In�S AQD <br /> l9 lho Pupil:Rnean,r CMIp••cl•oa t29G0,Trd miry.n..�n In�v l peadltlt:up to%25.nnn p+y ;a wanron ra•Ny•!dn.c•Ihdd In puobe Fn•oum•CnAe ft-Oon A 2301 <br /> !!!vlolnlon or•(Iminl•IM,' —'d-r uo to.•i 00 0•,vin•.•dnn rn•Any nr.a!'a,Vmd n p'�I.. <br /> h-"oumo Coda•mo'on.u ' <br /> c��9ardr T [ )Imported Load [ ]Exported Load and Location Hauler Exemptlon Status: <br /> Address [ I Government <br /> W [ I LEA Exempt <br /> City State, [ ]Agricultural <br /> Common Carrier <br />