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0 --7 e ,� WOP.I<iJRdER/MANIFEST <br /> �7 CJ 1274877' Tl,i 455 61 <br /> -Wafite Tire Hauler Waste Jim.Generator. <br /> McCoy Truck Tire Service Center, Inc. : V .[ '/01, <br /> t P Cl <br /> 1407 Lone Palm Ave. Address: 161 L11-Is C, <br /> Modesto,CA 95351 City; � '; �� f G Stator• <br /> 209.521-6221 Zij.r-- P <br /> TPID-1274877-01 TPID with Suffix: 17,"-• Ci g':� <br /> Load Date; ' ~� tt r <br /> �' U rC:' ; 'f Lq Load Type. whole [ ]Cubic Yard ( ]Ton ( ]Pound • <br /> Decal ,jPick-up count: ————I <br /> License :`7, .J ! ;1G.'�tatek", Dot coax: RWDY 1*[ ]Delivery count: <br /> [ ]REGULAR'TIME [ ] OVERTIME ;[1 CAU.OUT CUSTOMER PO# <br /> FLAT REPAIRS WI•ti NITCHES MT/DISMT <br /> LICENSE NO, E ICLE MAKE•"Y r MILEAGE I---,Q G �a) VEHIA- NO,' G �A <br /> LOCATION:; ��:�) J ��.:..�. �','16 C. <br /> -WORK PERFOR ED: +++ <br /> ':'L'­-`— <br /> .._-.-.� _.... <br /> rte. <br /> "�. MILEAGE IN <br /> MILEAGE OUT <br /> ' 1. • TOTAL <br /> ----• _...___.... . I N <br /> P .t <br /> ,,J�-'�:T 4'• (� r;t',,� r. _C� �1 �� �1 L ;�•,r TIME OUT <br /> SIZE <br /> SMFG. DOT# TR <br /> REAIS ... ... .. WHEEL <br /> Y (r ITr <br /> . y, <br /> 4 <br /> 5 � <br /> 6 <br /> 8 <br /> Drivers Signature �•� �:(; -G,� �% :h�I, rJ,-G �iduStomer Signature; r 4 I...'k, ~` �j.1ir Date: <br /> Drivers Name(print) . I'' Customer Name(prinl}, r,-p.% r:(. C r] C;1S. <br /> I mIIfy Thal under pnniPy.or perh+ry under tMo lave 011111's <br /> f lho,Stale of Ca'Ir f ,the Iforinptlon ],car Ifey lhm undrx pnnnly of pnrJury under Me,taws Ef Ihn swq of Callfornfs Ihai.iho Infomullon <br /> reeaavvit In'fouapenulonn"nvnrnrMn,Orden etllof renewal or ii allWaele Tire IliubrfRitlglcihtl n�purm+n nl roeul'If cCIIvllI PoniHlnU uvoo 32'000p oroddyyltloppnf��o,e bn orr adrnlnlfsrralldvGa penellbs uor o 6 QOOey <br /> to Iho Public Rnanurrsa Collo eoellon 42960 and mny rnault In civil pnnnitlnn np to 'r nn0 per tloy, pnr vlolallnn har day na nsenibed to P Ubllc Remwcm Cnde 9edllon 42962. <br /> per voleflon or adminlstr.'rrlva l+enAlileA up 10�5 <br /> .000 pef vlolellon per ley tflr dvaerfbod In Puhua <br /> oaouraa Coen siMlnn�2p62. <br /> o� Imported Load (' ]Exported Load And Locatiorf-f Hauler Exemption Status; <br /> Address: [ J Gdvernment <br /> [ ]LEA Exempt <br /> City,- State: [ ]Agricultural <br /> Common Carrier <br /> :Received Time Sep. 26. 2014 6; 2o. 1107 <br />