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WORK-ORDER/MANIFEST <br /> _. <br /> Waste.Tire Hauler Waste.T-ire.�Ganerato r <br /> 1h <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave_ Address: <br /> Modesto, CA 95351 City:r �,.:\_ � State: <br /> 209-521-6221 Zip:r �+ Phone: <br /> TPID-1274877-01 NTOID with Suffix 0-11-1 <br /> J« - <br /> Load Pate: Load T pe: ] Whble [ ] Cubic'Yard. [ ]'Ton `[ ] Podnd <br /> Decal # `�' - �. '� !I [;A] Piick-up Couht. — — —� - — — <br /> License #7'J:;q."' 'l State''�� Dot code: RWDY [ ] Delivery Count: <br /> SIZE MFG, DOT# TREAD WHEEL COMMENTS <br /> 3 <br /> 4 . <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> 16 <br /> 17 <br /> 18 <br /> 19 <br /> Drivers Signature. �_ _ �' Date:, - ,4 Customer Signature:iii. ,, ;,,�+, %;�r, , <br /> � , _ i • .ybrlvers Name (p iTmer Name (print) <br /> rndlly IIIn1 IInS19r pnnnldy of%parjury ufldor 1119 lawn ell Iltn Sino of CaII}nrnln Thal Ihn Infommllen I Miry II1aI rindnr pnnnlfy of pnrlury unnor Inc Iowa of Il1e s Inle of enlllnmla Thal.-Ilm Informallon 1. <br /> provldrd nbavn In tnlo Pad pnt{rrl.In nddhlon,I am nworo IMl W'111cNlOu Of No Ind?rmnllnn cony providnd nbovo It Inin Lind cmerl.In 806111nn,I nm nwnrn fhnl fnitiIlenllon of thla InrnrmFlrlon cony <br /> rnradl In navpminlnn•mvacnllon,or donlol nI mnnwnl of Iha Wanle Tlra Hmdnr Rnplatrnllor ourauornl rimil In co pnnalnn%up to 129.000 par day.M vlolallon or ncfmIN.91mllvo ponalUot uo Io$6,000 <br /> Io Fubllr Rominco codA aardnn 42960 and mev re9ttll In Wpnnntla:Up to$25•nOn par ony,par pnr vlolnflon por day an rjriWL1ed In pllpllr FifMnuran Codn noctlon 42062, <br /> --IolnNen or ndminlrtmtiv0 rnnnelnn lip to A10,0oo pnr vlofllfoT prlr dnv nr.drnerl0M1 In FUIXIa ' <br /> Roaouran t:odn nnollon-0@96'2, <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> orY,Datq'�L Address: [ ] Government <br /> lit [ ] LEA Exempt <br /> `.`1 City; State: [ ] Agricultural <br />