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/ ® WORK ORDER/MANIFEST <br /> 1274877-5 Q 8 4 6 6A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name. ^ y � � Y <br /> 1407 Lone Palm Ave. Address: 7 t. 5'. ' AV <br /> Modesto, CA 95351 City: tri State: ;. <br /> 209-521-6221 Zip: Phone: t" ' L'; <br /> TPID-1274877-01 TPID with Suffix: 'A <br /> Load Date:;",, ` Z L; Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal # <br /> —— — [ ]Pick-up Count: <br /> License#: I State: I Dot Code: RW <br /> DY <br /> [ )REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT (y <br /> LICENSE NO. VEHICLE MAKE MILEAGE VEHICLE NO. N_!J � <br /> LOCATION: <br /> a <br /> WORK PERFORMED. MILEAGE IN <br /> '.is V r- ' _?1 I (! --�.•- +r r._,*'_. ):: �� .'...,L,r� - Nv ` ,) MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> _ SIZE MFG. DOT# TREAD WHEEL �.-� COMMENTS <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: `, ,Ca," � , ,� Date: - 7 L( Customer Signature: __:--,*C �¢'�fr � Date: <br /> l <br /> Drivers Name(print) Customer Name (print) <br /> I certify that under penalty of perjury under the lam of tha State of California that the information I certify that under penalty of perjury under the laws of the State of California that the information <br /> provided above is We 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 falsificatlon of this information may <br /> result in suspension,revocation,or denial of renewal of the Waste Tire Hauar Registration pursuant result civil penalties up to 525,000 per day,pef violation or administrative penalties up to$5,000 <br /> to the Public Resource Code section 42960 and may result In Quit penalties up to$25.000 per day, per violation per day as described in Public Resource Code section 42962 <br /> P. <br /> r violation or administrative penalties up to$5,000 per violation per day as described In Public <br /> Resource Code section 42962. <br /> [ ]Delivery Count: Date ' ! f Waste Tire Delivery Point <br /> Z ! r 7 [ ]Same As Hauler <br /> odcDay T^d Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST �} 7„ [ ]McCoy Truck Tire Service Center ( ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> 1274877- t! 4 B French Camp,Ca.95231 Stockton,Ca.95205 <br /> rs 4 TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />