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t WORK ORDER/MANIFEST <br /> 1274877- 505724A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name:—T,- ( 0 ( # (!'� c <br /> 1407 Lone Palm Ave. Address: S �_.k 1 ^ V� - <br /> Modesto, CA 95351 City. rt State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: I j ] <br /> Load Date: Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ )Pound <br /> Decal # - ____ <br /> [ ]Pick-up Count: <br /> License#: ��� ) r I State: I Dot Code: RWDY — <br /> [ ]REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO#((,, <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT C <br /> LICENSE NO. VEHICLE MAKE MILEAGE SCI rI VEHICLE NO. '!t <br /> LOCATION: G1 + l ✓ r //. l% r ss J ? + J �! <br /> r <br /> WORK PERFORMED: / 7 MILEAGE IN / f <br /> L t L % I / l 12-4--, Y rr e-v, IJ v V ' .f lC.r r '. MILEAGE OUT <br /> t. ..i /fir'r t CQt'� ��'S ? J �"►. TOTAL <br /> Y , <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL r'`�, COMMENTS <br /> 2 .. <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> RE-TORGUE LUGfNPTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DAYS <br /> Drivers Signature:// & ;ill>At! Date: J11- : Customer Signature: &;/s Date: <br /> Drivers Name(print) L' Customer Name(print) t. <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 perlury 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 infommation 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 Registrazn pursuant result civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 <br /> tothe Public Resource Code section 42960 and may result in civil penalties up to 325.000 per day. per violation per day as described in Public Resource Code section 42962, <br /> per v�claaon of administrative 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 /> dcoaw T 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- 7 2 A, g French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br /> .Il,. <br />