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'�-~''~~�°'°�~----~`. .. <br /> / WORK�R�[:R/MANIFEST <br /> j 1 �� � r�,� <br /> 5 4 �� Q <br /> ator <br /> � <br /> McCoy Truck tire Service Center, Inc. Name <br /> 14O7Lone Palm Ave. <br /> Address.- <br /> Modesto, CA0S351 Ci / ^���'0V~ State: <br /> 209-521-6221 Zip: Phone: <br /> TP|C-1274$77-01 TP|Owith 3uffix� <br /> � <br /> Load Date: Load T�po; j,'j Whole Cubic Yard Ton Pound <br /> Decal # r-'Pick-up Count: <br /> License State: Dot Code: <br /> � <br /> - _...........-... __ ---___.. - <br /> 4 <br /> _---------- <br /> 5 <br /> -- ^------' -------�— ' '� '---------� ''-'- � ----------'� '-----'- -------� -----------�----1 <br /> 7 . <br /> ... ........... <br /> 8 <br /> 8 <br /> 10 <br /> ........... <br /> 11 � <br /> lu <br /> 14 � <br /> 1� <br /> 1O <br /> - '_---_-_' <br /> 17 <br /> 18 <br /> 20 1& � <br /> 2O � <br /> Drivers` Signature: ( ~~-� ,~- Date: � -'Z / Customer Signature: Date:Drivers Name(print) � <br /> W/~ <br /> ' �---_ Customer Name(print <br /> ��� �$�h�- <br /> wuma p����a���^*�m�� ' ' -rWed-- --� �-'-----�--' <br /> ' <br /> [ ] Imported Load [ ] ExportocLoad and Location Hauler Exemption Status: <br /> Addnauo' <br /> ' [ ] Government � <br /> LEA Exempt <br /> City State: [ ]Agr�uKdmd <br /> ' -- ]Common Carrier <br /> A�C� ' v�d Time Sep, 26. 1O1& K�31 ^,V. 1100 � <br /> ` - -' � � ' <br />