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d o <br /> WORK ORDER/ ANIFEST <br /> O Ca4O3u r-4 <br /> dao <br /> 1274877-50 1 5A <br /> Waste Tire Hauler ', Waste Tire Generator <br /> I McCoy Truck Tire Service Center, Inc. 14I 1me:0,6F,,i Q /�'���^ N1c+(,r1 ALS <br /> 1407 Lone Palm Ave. q �j Alress <br /> Modesto, CA 95351 Cityt, 9C State:&--k 1 yl <br /> 209-521-6221 Zip: --%1i60 Phonf�. ( ,G J) <br /> TP I D-1274877-01 TP I D with Suffix: (O tacqo;—40 <br /> Load Date:�b/ )S Load Type: ,Whole ( �Cubic Yard ( Ton [ } Pound <br /> / - <br /> Decal # 1 S `; pick-up Count: <br /> License#111�60C)'��1 I State:(,-,k I Dot Code: RWDY <br /> &REGULAR TIME [ ] OVERTIME [ I CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS I WHEEL SWITCHES MT/DISMT"'� <br /> LICENSE NO.L✓P)a3q,5_ VEHICLE MAKE MILEAGE VEHICLE <br /> LOCATION:12 *:' r� <br /> WORK PERFORMED: �^rllr +'C'V L j © ',5 �,..a(l r �(L�r( MILEAGE IN 1��Q(n��� <br /> Z) V C��C" ,rel_ �_��Z -�C,1 � _L`__ - MILEAGE OUTCL-t� - <br /> r <br /> TOTAL <br /> s t <br /> -��. -- - --- <br /> 2,a-*-t _ _ TIME IN -3 14 <br /> Lf <br /> f T}vol (L�,f..� ©'�. �gs� TIME OUT Q <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <br /> 5 '-ta rCJ ---- <br /> 6 <br /> 7 <br /> 8 ,_... <br /> Drivers Signature Date: Pustomer Signatur� _ Date:f �Z <br /> Drivers Name(print) Customer Name(print) <br /> I certify that under penalty of perjury unoer the s of the Stale of California Thal the information I certify that under penally of perjury under the laws of the State of California that the information <br /> provided above is true and correct.In addition, am aware that falsificatfon of this information may provided above is true and correct.In addition,I am aware that falsificalion 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 r^ny 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 r administrative penalties up to$5,000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> (J> Qelivery Count: —_ Date Waste Tire Delivery Point <br /> ��� ( 5 [ ]Same As Hauler <br /> o�,c Dara PFJ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST ?„ [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> q �^ 10850 Harlan Rd, 1537 E.Market St. <br /> 1274877-5; 0 4 0 ! 5B French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />