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Ii WORK ORDER/MANIFEST <br /> 1274877- 5 06 0 00A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: ] / <br /> ( rr , <br /> 1407 Lone Palm Ave. Address:-? 4 �;C <br /> Modesto, CA 95351 City: - 1' - State: ; <br /> 209-521-6221 Zip: Phone: C <br /> TPID-1274877-01 TPID with Suffix: - L{ <br /> Load Date: Load Type. [ J Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal # - ____ <br /> [ ]Pick-up Count: <br /> License#: I State: I Dot Code: RWDY <br /> [ ]REGULAR TIME [ J OVERTIME [ J CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS WHEEL SWITCHES MT/DISMT 01 <br /> LICENSE NO. f f Il VEHICLE MAKE MILEAGE?14-1 17!C VEHICLE NO. ' J ►`7 "i Lt <br /> LOCATION: L1 . ( = 1 t . ;_Lt 7 L-1 <br /> u <br /> WORK PERFORMED: / MILEAGE IN <br /> )l L 1 L e'—<_L I llJ���eA r MILEAGE OUT <br /> TOTAL <br /> 71 <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 2 <br /> 3 <br /> 4 <br /> 5 <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: k-A-0 , /„t v"P� Date: /3 <br /> Drivers Name(print) Customer Name(print) ll ,`'v f, \ '" <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 Califomie 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 conect.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 to$25,000 per day, per violation per day as described in Public Resource Code section 42952, <br /> per violalion or administrative penaLies up to$5,000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> Waste Tire Delivery Point <br /> [ ]Delivery Count: _____ Date [ ]Same As Hauler <br /> c�cData T� Waste Tire Delivery Point Waste Tire Delivery Point <br /> So <br /> WORK ORDER/MANIFEST [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E.Market St. <br /> 1274877- U 6 Q Ll a , B French Camp,Ca.95231 Stockton,Ca.95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />