Laserfiche WebLink
O <br /> t r ® WORK ORDER/MANIFEST <br /> 1274877-508376A <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: i <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: [ ]Whole [ ] Cubic Yard [ J Ton ( ] Pound <br /> Decal # - _ <br /> —— ]Pick-up Count: <br /> License#: State: I Dot Code RWDY <br /> [ I REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. VEHICLE MAKE MILEAGE VEHICLE NO. t 1 <br /> LOCATION: <br /> WORK PERFORMED: MILEAGE IN <br /> MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> ,TIME OUT —T <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 /> provided 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 information may <br /> resultin suspension,revocation,cr denial of renewal of the Waste Tire Hauler Re@ stration pursuant result civil penalties up to S25.000 per day,per violation or administrative penalties up to$5,000 <br /> to the Public Resource Code section 42960 and may result in civil penalties up to$125 000 per day, per violation per day as described in Public Resource Code section 42962. <br /> per violation or admimstrative penalties up to$5,000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> [ ]Delivery Count: I Date [ Waste Tire Delivery Point <br /> ] ry __——_ ]Same As Hauler <br /> NcDaN T^ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST s� °�^ [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E.Market St <br /> 1274877 V �t L / B French Camp,Ca.95231 Stockton,Ca.95205 <br /> V J / TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br /> r <br /> Yw: <br />