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O� <br /> r� Q) V WORK ORDER 1 MANIFEST <br /> O <br /> 1274877- A <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: <br /> Modesto, CA 95351 City: State: <br /> 209-521-6221 Zip: Phone: <br /> TPID-1274877-01 TPID with Suffix: <br /> Load Date: Load Type: [ ]Whole [ ]Cubic Yard [ ]Ton [ ] Pound <br /> Decal # __ - <br /> — [ ]Pick-up Count: <br /> License#: I State: I Dot Code: RWDY <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 /> J 1 y, t s [ i✓ 1 41 ` ,: li MILEAGE OUT <br /> �'�L1 f ',t'V 4 kJ 4' ` •�__�- % �'� L"1a1 l G. 1 1 11 A TOTAL <br /> TIME IN <br /> ,TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 3i_i � <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: t Date: l i(tl)Customer Signature: L i/�I16s; Date: <br /> Drivers Name(print) + ' 'i 1 -- . ? Customer Name(print) 11 � k A <br /> I cerb!y 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 Registration pursuant result civil penalties up to$25.000 per day,per violation or administrative penalties up to 55,000 <br /> to the Public Resource Cade section 42960 and may result m civil penalties up to 525,000 per day, per violation per day as described in Public Resource Code section 42962. <br /> per violation or administrative penalties up to$5.000 per violation per day as described in Public <br /> Resource Code section 42962 tt <br /> ( ]Delivery Count: _____ I Date i I Waste Tire Delivery Point <br /> [ ]Same As Hauler <br /> ��Data T^ Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST S° ' [ ]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 />