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WORK ORDER/MANIFEST <br /> 1274877— 5 4. 1:x, A' <br /> Waste T'ra Hauler- Waste Tire G nerator . <br /> McCoy Truck Tire Service Center, Inc. Name:c <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: Li State: t <br /> 209-521-6221 ZIP: 1?.. (,) t Phone. <br /> TPID 1/274877-01 TPID with Suffix: .� <br /> Load bate: / fl' Load Type: [X Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal,# �.�� „ �'- f � [/J.Pick-up Count: <br /> Lldense#: :-`t . j�.N ! I'StateDot Code; RWDY ]Delivery Count:— <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 <br /> ... <br /> 4 <br /> 5 <br /> •7 <br /> 12, <br /> • <br /> 10 --. -- — — <br /> f4 <br /> 15 <br /> ;i6 <br /> 17 <br /> 1g ' <br /> 20 - <br /> Drivers Signature: Date: Customer Signature : F Date:- — C.,$ <br /> Drivers Name 1(print) �,. ��(,t 1 ! a,.. Customer Name(print]�. <br /> 1 anrlNy <br /> It under pnnglry of Dor try undor the lawn a the Store of Cel!omin that the lnformatldn Cenlfy lhAl I'T It pnth of".1,y,unrlar tp?Inwg I the 9111.of C:III}omin th,t the fnfchmatlon- <br /> Drovlde!I sbovs 19 Info ono carfgrr.In gddtllpn, am flwnfe thnl L,Llflcotlen df lhl6 Inrnrmnnon mny pravlded.gbovv It tru??Irl orrnrd:In additive, n n�waro that falsification of this Informnllan mny <br /> mwlt In nusponalvn,rovor6ticri eh denial of mIlnwnl of Ino well,Tlro Nvular R,0%1ratlon OUreUfilll r?sull civil ponntlm up to$251000 p?r nn,pnf vlola�Ion cr ndminIntmttvo panaltla6 up to 7,5.000 <br /> to tre rul;llq ryesotvc?Co 1q?naton 429GO and mill re?Ulr In civil ponsllleB up to h2S,1100 per any. pnr vlolctlon per oey +a dnsar bad In Puhllc Resoui 6 code seatlon 47?N2 <br /> pvor vlvintlon.or admin:ctrotiva ponNltes up Io;5,000 Der vie letlnn am!ny as dbeCdh?d In f1.UUllc <br /> Rnaourcv Ccdo vvcton 42962. <br /> Imported Load [ ]'Exported Load and Location Hauler Exemption Status: <br /> 'y Address: [ J Government <br /> R' [ ]LEA Exempt <br /> ` City State; [ ]Agricultural <br /> Common Carrier <br /> Received Time Sep, 26. 2014 6: '210 No, 1107 <br />