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0 <br /> WORK ORDER!MANIFEST <br /> 1274877- <br /> Waste Tire Hauler Waste Tire Generator <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: Load Type: ( ]Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal # - <br /> —— — [ ]Pick-up Count: <br /> License#: I State: I Dot Code: RWDY 1 <br /> [ ]REGULAR TIME [ ] OVERTIME ( ]CALL OUT CUSTOMER PO# ! <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT `F <br /> LICENSE NO. VEHICLE MAKE MILEAGE VEHICLE NO. <br /> LOCATION: <br /> WORK PERFORMED: MILEAGE IN <br /> MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DAYS <br /> Drivers Signature: Date: Customer Signature: Date: <br /> Drivers Name(print) Customer Name(print) <br /> I certify that under penalty of perjury under the laws of the State of California that the information I certify that under penalty of perjury under the laws of the Slate of California that the Information <br /> P <br /> rovided above is true and correct.In addition,I am aware that falsification of this information may provided above is true and correct In addition,I am aware that falsification of this inlornafion may <br /> result In suspension,revocation,of denial of renewal of the WasteTire Hauler Reg stration pursuant result civil penalties up to 525,000 per day,per violation or administrative penalties up to 55,000 <br /> to the Public Resource Code section 42960 and may result in ciwl penalties up to 525,000 per day, per violation per day as described in Public Resource Code section 42962 <br /> per violation or administrative penallbs up to$5,000 per violation per day as described in Public <br /> Resource code section 42962. <br /> [ Delive Count: I Waste Tire Delivery Point <br /> ry ou ——__— Date [ ]Same As Hauler <br /> ab Data p^ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST ° ( ]McCoy Truck Tire Service Center ( ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd 1537 E.Market St. <br /> 1274877- B French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />