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® O <br /> WORK ORDER/MANIFEST <br /> O <br /> 1274877-508006 <br /> A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: ;.E, _ <br /> 1407 Lone Palm Ave. Address: )o5() E <br /> Modesto, CA 95351 City: :_ t, . H `. U State: 1 <br /> 209-521-6221 Zip: Phone: G 011 1=7�'6 <br /> TPID-1274877-01 TPID with Suffix: Ki <br /> Load Date: ILI ((A , 16 Load Type: [ ]Whole [ )Cubic Yard ( ]Ton [ j Pound <br /> Decal #__ - 0 - <br /> [ __ $ <br /> License#: t ;5 1 -[State I Dot Code: RWDY ]Pick-up Count: ——_ <br /> [ ]REGULAR TIME ( ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <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 /> s L, 1 ► `1 �firi 1, _ --- <br /> 4 M <br /> 5- ,i ,,1 AA 1-1 L GG cc 75 <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 Stale of California that the information I certifythat under penalty of <br /> Provided above Is true and correct.In addition.I am aware that falsification of this information may <br /> p Y perjury under the laws of the Stale of Califomia that the information <br /> Y provided above is[me and correct.In addition,I am aware that falsification of this information may <br /> result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant result civil penalties up to$25,000 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$25,000 per da per violation per day as described in Public Resource Code section 42962- <br /> per violation or administrative penalties up to$5,000 per violation per day as described in Public Y. <br /> Resource Code Zion 42962. <br /> [ ]Delivery Count: —___— I Date Waste Tire Delivery Point <br /> [ ]Same As Hauler <br /> WORK ORDER/MANIFEST �o�cUata T^a Waste Tire Delivery Point Waste Tire Delivery Point <br /> [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E.Market St, <br /> 1274877-J 0 6 0 0(B French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />