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j.i <br /> � O <br /> 1 it WORK ORDER/MANIFEST <br /> O <br /> 1274877-4 U4 'JA <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: t C <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: t. -[ }�, J t J State: k 0% <br /> 209-521-6221 Zip: ', .. -'J Phone: ?_ 0 �'+ 13 (_4 ( 1 v <br /> TPID-1274877-01 TPID with Suffix: I ',�Q 10 4�1 - ► <br /> Load Date: Load Type: [ )Whole [ )Cubic Yard [ ]Ton [ ]Pound <br /> Decal <br /> -- — [ <br /> License#: ' ! i I State: Dot Code: RW DY ]Pick-up Count: ——— —— <br /> [ ]REGULAR TIME [ J OVERTIME [ ]CALL OUT CUSTOMER PO# lit <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT n <br /> LICENSE NO. , <br /> t! > > > VEHICLE MAKE MILEAGE VEHICLE NO. <br /> LOCATION: <br /> WORK PERFORMED: / } t,, ( :±, ' �` __ _ MILEAGE IN <br /> I l!Cit __-- _ _ MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <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 /> 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 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 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:he 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 v=.olaticn or administrative penalties up to S5 000 per violation per day as described m Public <br /> Resource Code section 42962 <br /> Waste Tire Delivery Point <br /> [ ]Delivery Count: Date [ ]Same As Hauler <br /> T^ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST ,�° d�� [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> 1274877- `�j� B French Camp,Ca.95231 Stockton,Ca.95205 <br /> G- ,4 1- TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />