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Aftl WORK ORDER[MANIFEST <br /> 12 <br /> s a <br /> Waste Tire.Hauier Waste Tire,Generator . <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407'Lone Palm'Ave. <br /> Address:`,' <br /> Modesto, CA 95351 City:M State: <br /> 209.521-6221 Zip. � t 3 3"1 phone: <br /> TPID-1274877-01 TPIU with Suffix <br /> Load Date: <br /> �c1�._F='�. tet. Load Type: `'] Whole [ ] Cubic"Yard Tori Pourid <br /> Pick up Caurtt: — — - — <br /> RVIIDY [ ] Delivery Count: <br /> State: r\ Dot Code: — — <br /> SIZE MFG, DOT # TREAD WHEEL COMMENTS <br /> 1 ~ <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 9 <br /> 10 <br /> 11 ._ <br /> 12 <br /> 13 <br /> 14 <br /> 15 - <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> 20 <br /> Drivers Slgnatln-e. �h _: k� Dat0u�4D1��`' Customer Signature: �� bate <br /> - - <br /> Drivers Name (print) Customer Name (print) \\6.j,'�, <br /> I annoy Hutt nnrinr pnnnIIV o1,pogary under Iha law-or 1110 8101x1 01 UnIllomfA Ihnl 1110 Inlorrllntlan I carft 11101 un(IAr pnnnay of pnrjury Lindnr Inn mwc o1 the Sta10 of M111amrn that 1116 111forr1 arl <br /> providod nLv%,o IO lriln and oarroel.in ndClllon,I nm nwnrn that InlolnNIIInn of Hr.Informnllou May prnvirind n6Dvn Is trun nr K[eorroc.III 6(Idlllon.I RM 7warn ihni falrinctillon of 11118 lnfnrinntlen cony <br /> mnull In nunpnnslon,ravo0A11on,nr dnnlnl of ronnwnl 01 IN Worm 1'ho I-lautof Rnpislrnllnn pursunnl rocult In 01v11 pGrAPIAn up to$25,D(10 par day,par vlol1f10n 01'ACIMInlrlrnllvn pon611100 LID 10$6,000 <br /> to htrhllr.pnnniamn Coda onotlon 41REIn and mny rnsull in clvll poMlllnn up to=,M por dAy.pyx per vinlnlbn par dov no descrIbs(I In N1:N1r,Finan imn On&.ncllon 4296^_, <br /> v1011111011 nY AtllYlltll.entivo pnnnnina up to s5slon par vinlntlon per day as 6A.C.Phod In public - <br /> ROaouren Can nacilon 42961. <br /> [ ) Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> os`G atcrP Address: [ ] Govemment <br /> p <br /> PCU [ ] LEA Exempt <br /> 5, k City: Statd: [ ] Agricultural <br />