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' 1 WORK ORDER 1 MANIFEST <br /> 1274877- 5 11 <br /> Waste Tires HaulerWaste TirQ,_gan-gra or <br /> McCoy Truck Tire Service Center, Inc. Name: .. <br /> 1407 Lone Palm Ave. Address: Pro 5 �. �^�:� � �h.F�,.4;;• ,�'� <br /> Modesto, CA 95351 City: L--�i ;l;vt.ry; State: (, <br /> 209-521-6221 Zlp:1 Phone: <br /> j \.. <br /> TPID-1274877-01 TPID with Suffix: l f� � � k o 2— ^ c" <br /> r s [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Load bate; ' ,x / Load Type: [ INhole <br /> Decal,# :r, ^ —_ <br /> '�f �. [/IPick-up Count: —— <br /> License#:�-''% j�-X/� ! [State lr Dot Code: RWDY [ ]Delivery Count:—_ <br /> SIZE MFG. D07# TREAD WHEEL COMMENTS , <br /> 2 <br /> 5 <br /> _. . _ <br /> 6 <br /> g <br /> 12 <br /> 13 <br /> r <br /> 11 ' <br /> 15 .._ <br /> •16 <br /> ,',.;• 17 <br /> Drivers Signature: �!�--^ Date: '` Customer Signature: Date: r� <br /> Drivers Name(print) 0 Customer Name(print) tl <br /> I anrtlty thrift urdnr pnnolty of porJury undor Ilw Iowa of°t o stote of CRIlrornln that the Wwril3tlon I aenlfy lnel unrtnr ponalty or pertury,unrw I"Inwa f tna 311119 of CnlBornln that tho lnfOtmatlon <br /> Orovlded above Ig 1R o e d IX rW1.In adddlon,I am aware thm w:iPcatlon or Ihle Inrnrmnrlon cony prwl lod.aba-It L i e?nd:orrnal:In oddlilon,I oro�wnm that fala ration of thea InfdrMAllon nary <br /> mauls In ttuapanrlon,ravocMan,a?denial Or rnnnwnl of lra Weale Ttm NnulOr RoglytratlOn purPLIAN r"01 Civil prannitlnn up to$25 00Dge nny,Far vioton dr rdmin1rtrnllvo panalOaE uo la 35,000 <br /> la the RUTA,,ResOurCe Cada vAdloh c29G0 and may.re?it,In clvll penaltIO un In,525,1700 ppnnr dny. par vlo13110n per day na dnscr bad In FUblla Rellourtra Code eeaWn 47Atc7, <br /> Forv.blodOn.Dr admtnfetrallvo ponalAeg iip to;85,000 Dar vlclnllnn pnr dny as dbacrlbed In Public <br /> Raaourco Codo coctlan d2862, <br /> br�cbnr3Tf [ ]'Imported Load [ ]"Exported Load and Location Hauler Exemption Status: <br /> ao Address: [ J Government <br /> [ ]I_FA Exempt <br /> City State, [ ]Agricultural <br /> : fir, .: )Common Carrier <br /> " Received Time Sep, 26. 2014 6: 2, No, 1109 " <br />