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i — WORK ORDER 1 MANIFEST <br /> '~ 1274877-- L: <br /> Waste Tire Hauler Waste Tire s—nerator <br /> McCoy Truck The Service Center, Inc. Name: l,(� L 77',j7..' <br /> 1407 Lone Palm Ave. Address; C Le, 't'A <br /> Modesto, CA 95351 City: `�• State: <br /> 209-521-6221 Zip: <br /> �r' Phone: <br /> TPID-1274877-01 Tf�ID with Suffix; " '1 C <br /> Load Date: Q2-2.(,, -1, V Load Type; [A Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal # I - ZL' r JIPick-up Count: <br /> k'i state: Dot code: RWDY ]Delivery Count: _ <br /> License :�, / h`,'' ~ h I ,'l^ rY <br /> SIZE MFG, DOT#t TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <br /> 4 .._ <br /> 6 <br /> .7' <br /> 8. • <br /> 9 <br /> 10 <br /> 11 ' <br /> 12 <br /> 13 <br /> 14 <br /> 17 <br /> 18 <br /> f <br /> 19 <br /> 20 i <br /> Drivers Signature- ' <br /> g / " : Date: "�r„ Customer Signature; Date <br /> Drivers Name (print) �:'� t + 1 ,,, Customer Name(print) l ll` L.- '1 t�;;',. I�;l,� <br /> I certify th it under papally of pagnry UndortHOl'oKc of the Slnld of Cnlllornla that thn.lri'rrmarion I co,11,Ihnt un r', nnity at, ry andel IhE;latus of the rrtla of C911rornla Anil tho'nfcrmntlon <br /> prevldnd dhows le Inre and eormct.In add't',an,1 rm divas n-,nt fAlalflcannn of twi infMlnalbtl may pmvklnd above IP tree and coneaL In nddlllen,I am awaf 11, f61819cntivn of thin Infarmapon may <br /> mpfilFln BU6Danclen,rnvorarlon,or dental or rah9vu31 of Ike W21e1011ro hledlar Reglclrntlon pur.+nanl result tavll ponahlvs up to 529,000 par day,par vinlfitfbn or ndminlnrmgva�,+nN1198 tip to 55,000 <br /> to',ho public pn.rnrca Code 6ocllan d2aG0 and mnv ranult In croll pnnoltlrta up m;hZ�,fJpO Irger d'ty, par vlolndnn par riny as rinaarlhgrl in P11411c Rtecuraa Corin aeotl0n 42692. <br /> 'ppar vinl9tlor,or sdminlntrntivn hnnnPlea up In 45004 per vlolEllnn per d'ty as tlascrlhotl In Publlo <br /> RaeoPN.9 Coda cectIon a2f187. <br /> ) Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> Address: [ ] Government <br /> A <br /> P, [ ] LEA Exempt <br /> City State: [ ]Agricultural <br /> _ d [ ]Common Carrier <br /> Received Time Sep. 26. 2014 6, 32JM:N' o, 1109 : <br />