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f t ® WORK ORDER/MANIFEST <br /> O <br /> 1274877-5'387 '-A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name:~P _f' )) ` t } V yl r <br /> 1407 Lone Palm Ave. Address: c S C L t_G lA <br /> Modesto, CA 95351 City: _0 State: t _ <br /> 209-521-6221 Zip: - 1 Phone: el S ' - L <br /> TPID-1274877-01 TPID with Suffix: ! Cr LI L I' �i r <br /> Load Date: Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # <br /> —— — [ ]Pick-up Count: ----_ <br /> License#: I State: I Dot Code: RW DY 77 <br /> ( ]REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT e <br /> LICENSE NO. �/�-t VEHICLE MAKE MILEAGE f_VEHICLE NO. <br /> LOCATION: ! .-' r t 1 V I'll,I <br /> WORK PERFORMED: l MILEAGE IN <br /> MILEAGE OUTZ37 <br /> / V , <br /> t!`✓r J W, f If` >,1 L_��� �� ,t TOTAL <br /> 7 D rL4 <br /> I T <br /> TIME IN <br /> TIME OUT ,r C'lr t�l <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: Date: Customer Signature: Date: <br /> Date: h (� <br /> Drivers Name(print) Customer Name(print) iv xiuk""A <br /> I certify,that under penalty of perjury under the laws of the State of Cafifomia that the information I certify that under penalty of perjury under the laws of the State of Calitomia 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 /> result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Reg stration 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 t 525,000 per day. per violation per day as described in Public Resource Code section 42962. <br /> per violatlon or administrative penalties up to 35.000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> [ <br /> ]Delivery Count: Date Waste Tire Delivery Point] ry _———— I �' — 0 [ ]Same As Hauler <br /> �cOaW p^ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST s° °2 [ ]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 />