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k c Z r WORK ORDER/MANIFEST 4 <br /> o rq r + ]j�Q"�'] <br /> t �PIh�'rf X12°f �'CV I:/ <br /> gio i. <br /> ,4 `}' 'Ire:Hap�ar kV1�ti #� Tire <br /> --- <br /> McCoy Truck The Servloe Center Inc. ams:r� �z, 1i t0 � '✓"f� � ' <br /> 14Q7L4�hePaitrl'Ave' AddresIc�x � C <br /> Mbd@sto, CA 9835] } City �' d �State <br /> 209-521-r�221 xjp �v' ' Phone: <br /> 78770 x, ;; .`rTPID-12 <br /> LvaI, . <br /> d <br /> Date: # " �� Lclad Type; /hole [ ].Cubic Yard [ Ton J Pound <br /> (]ectal;# - � „ <br /> ]'Pick-up Count: <br /> License'#: � .;.I State: Dot code: RWDY <br /> REGULAR TIME [ ] OVERTIME [ ]CALL OUT. CUSTOMER PO# ` <br /> FLAT REIaAIRS WHEEL SWITCHES MT/DIS <br /> LICENSE-.N6 " VEHICLE MAKE MILEAGE"1` VEHICLE NO. <br /> 4CATION <br /> ` H <br /> )�,QRK PERFbRMED: MILEAGE IN ' f <br /> f 4£},t"r J K 1, (. I r:_�' r !` �`l MILEAGE OUT f 'Sr fit!• i� s <br /> t, . <br /> TOTAL' <br /> r �. <br /> , <br /> Q4 7 z Is <br /> TIME IN <br /> i <br /> ,F v@bTIME YOUT �f <br /> 1'�, <br /> ,F SIZE MFG DOT# TREAD WHEEL COMMENTS 8., <br /> id <br /> A , , : <br /> T 777 <br /> ,r <br /> r; <br /> 7 <br /> RE TORGU LUG NUTS AFTER 50_TO 100 MILEa`^ -� NOT RESPONSiB !290 <br /> DS`LEFT'.OVER 3Q DAYS � �° <br /> Divers Signature. Date: f Custgmer Signature Date: <br /> Drlyers Name.(print),. ' nr� Customer Name;(print) <br /> 4 certify that ender pangltybf pp�,ury under .eYye p of Ce. rp14(� t the inipfrriaq 1 i01ON jhot ander panatty of penury uriao.thp laws of the State Callfcmlp ftiat{tte Infam aUr1n <br /> provided ebove.1, end 00,;6 t1In oddltlon, pnhpWery ttieI talvin tlon otth a Infpfmdtlflp IRpY. --provldad 0 0lp(rug,an correct,In ad avtgre that 4101Qdat(gn of�Shlf lnforma0on may - <br /> result In auepenalon,revooehon,or danlahof.renaWp(•of the ease:TI H�I@Vier F�gflla1ra11on pyrpuanF, result civil panaldpa.wo to 26,000 per day,per viol tion or edminlatragve peneiges up to$5,000 < <br /> to the Public R9eourcp Cady aaptlon'428oQ and ma result In clyll Rallaftleeuplo i26,000.ppr iQpy, ,par vlolatlon per day as described In Public Reaourde Code section 42862. i <br /> per vloletlor,qr administrative penaltiee,up W 56,000 per ylolaggn per♦t{fy ea dpeal6}9d In,Pyp)q ' <br /> Resource Cdde aedllon 42862. .. .. <br /> [ ]W <br /> I pate este The Delivery Point <br /> � <br /> ]Deiivery Count ,,..,. _,.. Same As'Hauler <br /> Waste Tire Deli* ,Paint W4te Tire Delivery Point <br /> WORK ORDER/MANIFEST [: ]McCoy Truck Tlfe Ser�Ice Center I ]McCoy Truck Tire Servlce,Center <br /> [3 10850 Harlan Rd. 1537 E.'Market St <br /> 1274877- French Camp,Ca.95231 Stockton,Ca 9505' <br /> TPID#1352986-01..Phone 209-982-0115 TPID#177897841, Phone 208'652-0434 <br />