Laserfiche WebLink
v ® C7 WORK ORDER/MANIFEST <br /> a4 D 1274877- / / 244,5 <br /> Waste Tire Ha uI _r Waste Tore renerator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 <br /> City: State: r <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: [ ]Whole <br /> [ ]Cubic Yard [ ]Ton [ ]Pound <br /> Decal # - _ <br /> —— —— —— I [ ]Pick-up count: <br /> License#: I State: Dot Code: RWDY [ ]Delivery 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 /> 3 - <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> Drivers Signature: Date: Customer Signature: <br /> 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 certify that under penalty of perjury under the Taws 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 rs true and correct In addition, am aware that falsification of this information may <br /> resu4 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 S5 coo <br /> to the Public Resource Code section 42960 and may result in civil penalties up to 525.000 per day, per violation per day as described in Public Resource Code section 42962. <br /> per violafon or administrative penalties up to$5.000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> "IC Data [ ]Imported Load [ ]Exported Load and Location I Hauler Exemption Status: <br /> 2� Address: [ ]Government <br /> [ ]LEA Exempt <br /> City State: <br /> [ ]Agricultural <br /> [ ]Common Carrier <br />