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WORK ORDER/MANIFEST <br /> O <br /> 1274877- Q 5 8 8(A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: L c �r ' L ` t ��� A,- (- <br /> Modesto, CA 95351 City:_ U� Y l 1� State: <br /> 209-521-6221 Zip: - Phone: l- <br /> TPID-1274877-01 TPID with Suffix: t C.:L`1,( <br /> Load Date: Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal #__ -_ L� <br /> [ ]Pick-up Count: <br /> License#: ,I P; %r I State: I Dot Code: RWDY <br /> ( ]REGULAR TIME I ) OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> I i � 1, <br /> LICENSE NO. ( i- VEHICLE MAKE MILEAGE , M!- t ( /_ VEHICLE NO. I�r � 1 <br /> LOCATION: - {` r I t U f t v !-i. J" `- [ Z `. f ( ^ ! I' �V <br /> e t <br /> WORK PERFORMED: ( MILEAGE IN <br /> r- f: / _r ►�.� f n 11 Y .moi ! C e- 0 r?� 14 po,i J : 'i MILEAGE OUT <br /> TOTAL <br /> ( �1 -T- i CfV �u-101. -��� ��,� �Li It, , r <br /> L-1 Ll <br /> TIME IN ' <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> r , <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: is /�-y Date: Customer Signature: ]/,� ��.r��j ; Date: f <br /> Drivers Name(print) - �� .�, �� .fir s Customer Name(print) ,►�� /V t, <br /> Icertify 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 State 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 oortect.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 tc,$25.000 per day, per violation per day as described in Public Resource Code section 42962 <br /> per violation or admmistrative penalties up to$5.000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> [ ]Delivery Count: Date Waste Tire Delivery Point <br /> ( ]Same As Hauler <br /> oc'cDay p Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST 4 ( ]McCoy Truck Tire Service Center <br /> � y [ )McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E.Market St. <br /> 1274877- Q 8 5 0 1 B French Camp,Ca.95231 Stockton,Ca.95205 <br /> vv V VV TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />