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WORK ORDER MANIFEST <br /> 1274877- <br /> Waste Tire Hauler Waste-Tire GeneratoC <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: State <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date.- ",7 Lead Type:—[1]Whole Cubic Yard Ton Pound <br /> Decal # [XIPIck-up Count: <br /> License <br /> Dot Code RWDY [ ]Delivery Count: <br /> SIZE MFG. DCT# TREAD WHEELCOMMENTS <br /> .......... <br /> ..................... . <br /> 2 <br /> 3 <br /> ---------- -- <br /> 4 <br /> 5 <br /> -------------- <br /> 7 <br /> 8 <br /> 9 <br /> .10.1 <br /> 11 <br /> ............ —------ <br /> 12 <br /> 13. ............... <br /> 14 <br /> 15 <br /> 17 <br /> 18 <br /> .......... ——------ <br /> 19 <br /> 20 <br /> Drivers Signature: Date: Customer Signature., Date! <br /> pr t <br /> Drivers Name (print) Customer Name (print) I <br /> I htil undsrpqnsiiy Of 00rjUrY Undor Vie iows thin IhA Inflinnall,?n I rertiry met under per),.)Ily or ingrJury under Vie inwe of I"Stald of Caffl:rnlri thni din IriforrinAllon <br /> Pirl�IL "bOVD In Lrun rnd corrop.1.In orkitlon.I nm nwom that roldIfluntlon of INS Inrormillon may ;rmvIdodibcvn Is true and corrorli.ItinddItIon,I nm n%vptq lint Q%mr1lifin or ims Information Iniv <br /> ryl In re,008110,,or derl[lil of refevict of ViA WA%tn TIrn I-Inultir Fznlqit;tmtIori purmlAnt rApi Ill rivil perialIVAP iii,In$7.5,00 pqr dry. V[011illo)h or Lldmln elrollva perolIlas up to XCOO <br /> 1'.)Vie P, ljo r <br /> 0 (jeouruto Coda,action 4,90'0 and maytip In., n6nggrlpy, OS urw Coda clutter 4 2. <br /> .2,,, per vIvIciflor per day O.desorlbel In FuINI, U at an 290 <br /> robuii 6 ow P,�nvie <br /> 5;volitlon orndmIn1,Ir;mvarAnAIII4P lip In$5,1710 pnrY;oInflanpordnyilndcsrIhedl-i lc <br /> "Lirea Cf,.rl-antlon 429621 <br /> Ar Data ) Imported Load ] Exported Load and Location Hauler Exemption Status: <br /> Address: Government <br /> LEA Exempt <br /> City State: Agricultural <br /> Common Carrier <br /> Received Time Sep, 26. 2014 6: 2�'No. 1109 <br />