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V -- — <br /> WORK ORDER I MANIFEST <br /> 1274877 `�j A 4 <br /> Waste Tire Hauler Waste Tire Gsnerator <br /> McCoy Truck The Service Center, Inc. Name; ' <br /> 1407 Lonts Palm Ave. Address; 17f(� (�� F V (��7 <br /> Modesto. CA 95351 Cily:L State: _ <br /> 209-521-6221 Zip: „��� 7 Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date; (�-7r.G Load Type: [A Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal # _�f?Lt J 'APick-up Count: —— <br /> License 0: ;t state: l�- Dot Code: RWDY [ ]Delivery Count:-----, <br /> SIZE MFG, DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 5, <br /> 6 <br /> 10 <br /> 12 <br /> 13 <br /> 14 <br /> • 15 ' <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Signature: ��.� r.--��' : Date:i(,"'�r„ I Customer Signature; <br /> Drivers Name(print) ?(,t I,,•,.� I Customer Name (print) 'J `tom'. ,1r,� <br /> I Cor pfy That undor prannity of perJury undoiTMQ1'nwc of tho Stntc of Cnllrornla thnl thn.lrl'armnrlon I cartlfy thnl urdor pnnnity of pnrJ ry unUpr Ih9;AwS of tha�3inla or cF irwia lhttl ft Informrttlon <br /> provldnrl nhnve Ip Iroe end cormct.In ndditlan,I crr mvarn Ihnr fnlalflutinn rAthl?Infonnalbn may prnvlrinri qoo+�e IA true nod eorrecl.In nddlllon,I nm awarAAAAA lhal raldpcnllon of thin IOrormgllon may <br /> rg?i.dt In auAoarlsI m,rnvocnrinn,or Uenlal of ranowil of the Wtro1e Tiro I•ladler Ro Ictmtlon purvuant roeufl civil C^-nnhlon up to x`0,000 pnr dr ,pqr vinotlbn or adminlnrrnrlvn r,�ennlrlge tip to T5.000 <br /> l01ho Fu611a Rn.rurcw COUo cxllon 42BG0 and my rnault In alvll panaltlna up rol7,gp0 per U9y, pa viol nilrn par riny na rlgnnrlhgrl Ir f'Upllo Reeouran Codn agC110n 42E62. <br /> 'ppnnr vinlgrlon or admtnlntrndvn nnn1119A irp to$5,041 per uIOIBUnn pqr Uny ae tlgaorlhed In u6110 <br /> Rgaource Cod^cocUon 47A27„ <br /> <o��eDAEq ( J Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> Address: [ ] Government <br /> A <br /> LEA Exempt <br /> City State: ( ]Agricultural <br /> a Common Carrier <br /> Received Time Sep, 26. 2014 6: 22AM='IVo, 1107 <br />