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01✓06✓2013 10: 04 203-52: ;81 MCCOY TRUCK T7 PAGE 05✓06 <br /> VvvltK ORDER r MANIFEST - <br /> 5 6 <br /> 68318 I , <br /> Monte jjr Hauler 1Naste T Generator <br /> MoCoy Truck Tire Senrice Confer,Ino, Name; G <br /> 1407 Lone Palm Ave. Address; tp�.ks E l.Ci•4�- *ya <br /> Mod2Sto,CA 95351 \ Cl 5 <br /> ty I,8�11r�ro Q SCGIte: CVA <br /> /),., <br /> 209521-6221 Zip: cus 3 t3 0 Phor►e:r2� ��� �! � CJ <br /> TPID-1274977-01 TPID with Suffix: Lts 1 4%LA ^Q <br /> 40ad Date:`E� 1 I Z)17—Load Type; ,I Whola f ]Cubic Yard [ 17-on [ )pound <br /> Decal# <br /> I[ Pick-up t;c�unt: <br /> x _ __ , <br /> License 16-n 0 2,1 State: Qi"- Dot Code: RWDY I[ ]D®livery count: <br /> [�GULAR TIME. [ ] OVERTIME I ]CALL OUT CUSTOMER POO <br /> FLAT REPAIRS �� WHEEL SWITCHES MTIbISMT Inv�� <br /> VAD VYO <br /> LICENSE NO. ,,r�� VEHICLE MAKS r 1 MILEAGE VEHICLE NO. <br /> LOCATION: ► "� ,� AR� �.(.f-t Y1•r (� p c r—A, <br /> WORK PERFORMED; MILEAGE IN 40 <br /> ...,,,.,, ...---.. <br /> I,� )�V,0111111.L 'PCA C�, MILEAGE "f5OUT �;"`�� y <br /> �]vr� <br /> _......, TOTAL <br /> �z/ 2 Z:� �J t3•vt�V't<1� �ot'� 1 f �'� .. . — . C 'nn... Vti vtr <br /> ?'IMF IN , <br /> TIME,OUT <br /> SIZE MFG. DOT4 TRFAO WHEEI, COMMENTS <br /> 3�n <br /> 3 • <br /> 5 <br /> 6 <br /> 7 <br /> 8 � <br /> Drivers Signature: I Date: Customer Signature: pato:' ' <br /> Drivers Name{print) 1 CUStOmer NamO(print) <br /> I ED Ihgl under 1 Ally a1 oarlurryy LTdnr ws al fhn rm1n of Gallfemin Iha1 Ih•Informnnon I n�nl�y lh11 unJar hwtlry cf DogltN�nH�r Ihn IDWD of thn;m M eantomin Ih,l lh�Inrcrmnnnn <br /> DMv �A t} ovo h true And rorroth'In�, r7ltlon m nwDrrr tnm mlamcenv�pf IIptIx In'nrmnfo�may 1�rnv r,@d hove L91nJA Off cortvat.In aMlJhlan,I nnl R�lvnra qql(aldfl��han Af In1D InaOrritgnn mHy <br /> aankN In auePon,ian,ravoq�hen,Dr ann I nrrone t f the}varve ryy rlaulnr is Icr Alton pur7unm h?A A alvl�pnn.""w to a,6o0 r t11y,per vlelnllnn Or dminitnnllvg nnhlea up M A5.OQ0 <br /> to Ihtt Pubitc Faaonrag CddD a aptlen 4., o and m rnsu l 1 civ t panalnn�upp to ?'.0Do Dnt dny, Dar v�alanon aer, dny nn dnnrn nagr-ublt an�nn nn Cato:nt tmn n?Qg <br /> ver t4ofatlnn nr Mlminlarnnvn pDnahlOh u o 36,00 pgr�golallon Dat 0nynn MaeeZ-d in Puhllc <br /> F,anQnrVa Coda caaaon a7$(77., <br /> [ ] Imported Load [ ]Expot7:ed Load and Looatlon i-leluler Exemption Stcitun: <br /> Address: [ ]Government <br /> [ ]LEA Exempt <br /> ' Y <br /> City State: [ ]Agricultural <br /> f 1 Common Carrier <br /> Received Time Jan, 8. 2013 2. 25PM No- 0409 <br />