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OF <br /> ill b C <br /> WORK ORDER If MANIFEST <br /> 1274877— <br /> J hsla Tire N a uIor Waste Tir„GaneratQL <br /> McCoy Truck Tire Service Center. Inc. Name:; <br /> 1 .07 Lone Palm Ave, Address: <br /> Modesto, CA 95351 City: State: <br /> 209-521-6221 ZIP: Phone: dd <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: j` (' Load Type: ]Whole [ ]Cubic Yard [ ].Ton [ ] Pound <br /> Decal # ``,� - �;; � [,JPick-up Count: <br /> License Z I State: Dot Code: RWDY ]Delivery Count— <br /> WHEEL <br /> _� _SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> _.........-- ___...._.._ -— - -...__.... <br /> _. __. 5.... _.... _. <br /> 4 <br /> 6 <br /> 9 <br /> 11 ---—......... <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 17 <br /> 18 <br /> -19._...... _—............ _....... ----..—.... ......... <br /> __._....._._...__._........ ir.. __—... ..._.._ --.._..... . -----.._.. _.._. <br /> 20 <br /> Drivers Signature: l'1- Date: '” Customer Signature: —' <br /> 9 �- ( 9 Date:; <br /> Drivers Name (print) �� �"1,���.�� Customer Name (print) a (� '% llwl P-1110. ve <br /> I rrail!y that undorpnnalry pf penury Utldar tho Iowa of tho 9to(o cl�a,fornla NO rhn Information I carllfy that unner panally Of paY�Ury llndbr Iha lawn o�Irle SIE,Ie(/p0r,Cnllfomfn Ihnr Ihq lnrarmP�llon <br /> provldnd nbovn I?Irue nnC cannot.In addif an,t am nwgre 111at'a18109a11Pn or UtIB Information mny prnvlded above It,true and carrxl.In addon.I am oworo thnl rnlalflwifin or tole Infarnatlon cony <br /> rea.dl In eut:ponclon.rnvorallon,or denial of ronowol cf(ha 1A1ob(o Tiro Hauler RnSlatrwinn pursuant ronu'.1 aivtl pnnninea up to Rz5 ono per de ,por vlolalion x BdmInIB(FFativa po�nlrinn up to s6,000 <br /> (a thn Rrbiln Rlmurco Coda noctlon 4"A1 Mfl mqy feBUll In nivll WRItMB Up t0 526,000 por dny, pgr vlpletlOn per dty 06 deseribod In Publ�a Rnaoorc9 coda ioorlon 42% <br /> Far vlolatlon or ndminInimgve penaplea uo to$6,000 por vlolatlon nor day no donorlbnd In I'nblic <br /> ocauroe Coda unction nMZB <br /> ] Imported I-oad [ ] Exported load and Location Hauler Exemption Status: <br /> 4y Address: ( ] Government <br /> . [ ] LSA Exempt <br /> City I AgrlculturaI <br /> [ I Common.Carrier <br /> Received Time Sep, 26. 2014 6, 32AN1'.( No. 1109 ' <br />