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v � — <br /> ij t r WORK ORDER!MANIFEST <br /> 1274877— ;. <br /> Waste Tire Hauler j�1(, t,��ZiJ�Generator <br /> McCoy Truck The Service Center, Inc, Name: �t;�, r': �,,,;-�'• .,;,I �. 1h� <br /> 1407 Lone Palm Ave. Address; <br /> Modesto, CA 95 y' <br /> 351 Cit � �� i' State: <br /> ' <br /> /, ..I <br /> 209-521-6221 ZIP: „� x - Phone: <br /> TP.ID-1274877-01 TPID with Suffix: <br /> Load Date: 5, <br /> �(4 Load Type: Whole ] Cubic Yard [ ]Ton [ ] Pound <br /> � .. <br /> Decal # _L Li -S f;KjPick-up Count: <br /> License#2" 'Jj, j hState: ( Dot Cade: RWDY [ ]Delivery Count:__ <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 6 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 . <br /> '12 <br /> 13 . <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 !" <br /> 20 <br /> Drivers Signature: ",�.y ( `` Date:_� "�;�,, Customer Signature: ,� Date: „ <br /> Drivers Name tint ( ! Customer Name rint <br /> lo0r!Ify that"'o <br /> dnr Density of DerllRy under the leve'or <br /> qie Stele 0f ChIKomUS tfis4th9lnformsllen I Calllfy Ihnt under pondfy of perlury und0r Ihn In>a:l,pf thg Stefe of Cellforrib thm tho Informndon <br /> prov'UeU GbovO lc Iruo and aorrrrt,In ndAltlOn,I nm nwnmihdt f0101fIo0Hon of"I" <br /> In room"'."may nlw1`IPd sbov9 is lnln nno oorrnot.In so Ulllon,I orrlowaro that fnlalflamton of IMa lnr.)rnjM1oh hlsy <br /> rosull In nuap�ralon,revgos110n,Or dental of renewal Of the lNnAr?71rn�lgulr+'r qq latr't"on pUfeUenl •exult civil Dorbltloa LID to$25,000 Cor dov,par vlbIwInn or AnrnlnlsVFllve Denviloe up to$0,000 <br /> In the fv ll?IIC R06ourov Coda ana"n 42960 and mr)y r0^ull In 01v11 DOh0111ot:up le ^5,000 per dnv, nnr vlolnllnn rrr tiny na rinsrrlhad In PUhf!r.Re?Ol+fto Cedo s0otlon 42902. <br /> pper vloloilon cr odmin,otmrlva pnnBlline Up In 9L5,nn0 per vinlalbn pnr dny as doaorlbnJ In plAtillr. <br /> Rcoou J.,Coda ancllon[.2DBI, <br /> Date [ ] Imported Load [ ] Exported Load,and Location Hauler Exemption Status: <br /> Address: [ ) Government <br /> W [ l LEA Exempt <br /> City State: [ l Agricultural <br /> „uV:i •. , . [ ] Common Carrier <br /> Received Time Sep, 26. 2014 6; 22AM No, 1107 <br />