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or s` <br /> iii li-.,11 - <br /> 1!' ' WORK ORDER/MANIFEST <br /> _ O <br /> 1274877- 61 <br /> Waste Tire Hauler- Haste Tire Generator <br /> McCoy Truck Tire Service Center, Inc, Name: <br /> 1407 Lone Palm Ave, Address; <br /> Modesto, CA 95331 City: ..-; I State: uz�h4' <br /> 209-521-6221 <br /> ZIP: Phone <br /> TPID-1274877-01 TPID with Suffix: '�'� sr�1 "'�•� <br /> Load Date: Load Type: Whole Cubic Yard <br /> Yp �l [ ] [ ]Ton [ ] Pound <br /> Decal# 9 - ,; � [.-Pick-up Count: <br /> License#: !ir„?4�'> I State: ( Dot code, RWDY [ ]Delivery Count:_ <br /> _.. - .. ..._ . ...... _._...... WHEEL COMMENTS <br /> _.SIZE MFG. DOT#------ TREAD . ........_._.___._.... . ._....---._._ _..----- _... --- -. . ..... <br /> 1 <br /> z <br /> 3 <br /> 5 <br /> 8 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 1G <br /> 17 <br /> 18 <br /> 19 <br /> -- ......_ _ ............_...... .._.__�.—.... -- ........... 1._.....-+--..._. . ..._...._...---.._.,... . - --.._.. <br /> 20 <br /> Drivers Signature: �''1-��. Date: " "4 ; Customer Signature: <br /> �;.� g •,,, � Date::. , <br /> Drivers Name (print) Customer Name (print) ! ti V <br /> f oertl!y diet undorpmmty or perjury under the Iowa of Iho Sloto cf Colllornle lhnl tho Inrnrmnllon I cnrllfy Thal in,or ponAlly or p9rJury Under the lawn of tn9 31o1e(of,Collromin thni Ih9 lnformellon <br /> provldntl nbcvra I?(lie ane cannot.In AddHlnn,I Aryl Awafe 11191!aIAITlratlon of Iltle Informallon mny nmvlUed abovC Ic Iruo and cor12 rn nddltlon,I em aworo thnl rnlolfflC9tlorl of Nit Information mny <br /> moiAt In BUBponclon,rnvneAllon,or den101 or ronowol of Iha Weelo Pro Ntrular Ro jbIratlnn n!PBUanI Msuh o1v11 pionnll199 inn to F26,on0 perdey,per vlolalion or atlminIZ5tivo onclrinn up in$5,o00 <br /> tC thin Publlr•.R9soureo Code aactlon 449611 70 Rt' r96Ull In olvtl p9naltle9 lip to 525,000 Cor dny, pAr v101911011 Cor diy,15 derxnbed In pubic we <br /> Codt e;ootlan a7.% <br /> Ar vlola lon or ndmtnintr,tale penelllee up to 36,600 por violodon por dey na dasorfbnd in uhlle <br /> PA <br /> Catln rection 4^,002, <br /> {c!�GD,ri,r� [ ) Imported Load [ ] Exported Load and Location Hauler Exemption Status; <br /> Address: [ ] Government <br /> LSA Exempt <br /> City Agricultural <br /> [, ] Common Carrier <br /> Received Time Sep, 26, 2014 6; 22AW No, 1107 ` <br />