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vVOP.IZ ORDER/MANIFEST
<br /> _,— 7 ,� 1274877- T,,Ii —%
<br /> Waste Tire Hauler Waste jjre t�Ibc
<br /> McCoy Truck Tire Service Center, Inc. Name:' t i"r, V.(!'/&\_7 G�
<br /> 1407 Lone Palm Ave. Address: L✓j S Lam „ ', �'� G' '' yr !.I
<br /> Modesto,CA 96351 City; � '; �r��f 0 � State--.6k.
<br /> 209-521-6221 Zip, i ,J Phone-C, ,,.• J,-'1�� } (r, t
<br /> TPID-1274877-01 TPID with Suffix: ,',
<br /> Load Date; Load TypeWhole [ ]Cubic Yard ( ]Ton ( J Pound
<br /> Decal .[ ick-up count:
<br /> Licensa#; 1�(<," T;)C. State ,-r� I Dot Coda: RWDY [ ]Delivery count:
<br /> ( ]REGULAR TIME [ J OVERTIME %{ICALL OUT CUSTOMER POO
<br /> FLAT REPAIRS 4 Wf fEL,S (ITCHES MTIDISMT
<br /> LICENSE N0. or,� �EICLE MAKE'YY . �'�MILEAGE�-ti; <. �a1 VEHICLE- NOS
<br /> LOCATION:
<br /> WORK PERFOR ED: i
<br /> _...... MILEAGE IN
<br /> MILEAGE OUT.... f
<br /> TOTAL
<br /> 1' I
<br /> TIME IN
<br /> .' r� ------_.__._._.__._........_�_,,...,, . ... ........ . . . ....,.__.., . ._._._...... .�. •.,rte_. .
<br /> TIME OUT
<br /> SIZE MFG. DOT# TRM WHEEL .--., _ COMMENTS _
<br /> r
<br /> 3
<br /> 4
<br /> 5'
<br /> 6
<br /> 7
<br /> 8
<br /> ature�f •� ', -�. ' v r� d r\, � f'-- --, - t;�.
<br /> 9n ustomerSignature,
<br /> Drivers Si Date:
<br /> Drivers Name(print) I�'1�.i.0. �' u i t� ''Z_ V dustomer Name(Prin6l,�r-I .iJ-�---
<br /> I t 9rllly Ihat undor pom ly.or p,,', ry unlet Iho,_,wo or Iho;slnto of 0111forpkihpa�!Iho htfo,,1,n n boortlfy lhol undnr pnnnity of pnrJ.1J under INS,19we Cf thn P,tntn N allromis Iltal.iho Inf 113n
<br /> result Inloucoon is
<br /> v Horn or d9n1e„lo�ronev of or illollWNIe 71M tiiaulor Rdg1ldVhllBn�pv a tl rocul?clvN penelllnn UPto52E 000 phn0ddyl,Wif lvl0lnl on o9 mdm�nllAt AIOu9 pen81lb6 G o 58,0005y
<br /> 10
<br /> the Publk Rnaourro Code tocllDT,4.2900 and mny ranult In dull pnnnlona up to$7,n,,goo per dtoy, pnr viowinn par dny oa nam@ed M rubllC Resouren Cnde 89ollon 42A82. '
<br /> per vlol9llen or odminl�rrntive enfilllea up to F5,000 peg vlolellon per day 0 dxalbod In Public
<br /> onnuraa Codn.w inn 42082.
<br /> Imported Load [' ;]Exported Load And Location'-f Hauler Exemption Status;
<br /> Address:
<br /> [ J Gdvernment
<br /> [ ]LEA Exempt
<br /> City,. Stato: [ ]Agricultural
<br /> Common Carrier
<br /> KX.' u
<br /> Received Time Se•p. 26. 2014 6: 32A N0 1109 ”' ;q
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