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r I WORK ORDER/MANIFEST <br /> 1 . 11tr ' <br /> 1274.877 , C� <br /> Waste Tire Hauler ' Wase Tire;Generator <br /> McCoy Truck Tire Service Center, Inc_ Name: lw ,:t}� y �� �w1]tri:. L;(r', j;ll i <br /> 1407 Lone Palm Ave. Address: `� "�1 �:'' l <br /> Modesto, CA 95351- city. State: <br /> 2097521-6221 Zip: �1',. _ '.;y� Phone*'i <br /> TPID-1274877-01 TPID with Suffix I -;�] <br /> ..� r� �; Load Type: ['�] [ ] Cubic <br /> Load Date: l �' Li I > Whole Yard [ ] Ton [ ] Pound <br /> Decal # c+ - ' i ^"? [-A] Fick-up Count: — <br /> License # -=;5� State: Dot Code: RVVDY ] Delivery Qount: <br /> .SIIZE1._ MFG. DOT # TREAD WHEEL COMMENTS <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 n <br /> T71 <br /> 8Ile <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 Signature 1 „ ) Customer Signature: �, �r %� , ,� ? .,,1�rr '' Date: <br /> Drivers Name (Rrint) J�'�' ” �'' �, �- �1"t� Customer Name (print) <br /> rorllly Inal undor pons ty o parlwy unWr 1110 Irwi or tha {olu of!alilcRa thGk lhu inicrmuaan l con ty 1 t undor panalty a1 I, or <br /> or ury un M ICY76 o U,VSlbld of CiIIIII)RAG Owl In.Information <br /> OeWlud above Id uub a,id cormel.In andllian,I dm uwaru dial Iala Iuniol UI II11b 1111urrrmllwi may Dmviddd dWvb le lruu and eorrual.IIIdddlllUll,111111 U"rJ Ilial"-ificadon of tel:InlJrmadon 1rWy <br /> raaWl In:ualmn7lan,ravacaUw,UI Wnkd UI rwmwal of tho Wa:la Yim HuWor Rudlaumlcn puruumv rc:lih In civil punullloJ up m$:G,00U per duy,pur violauull ur adndulalidllau Uvnulliac uh lu SS,G00 <br /> Iv Publla Fieauurue Curie eeulan 42bw and may rubU11 III Civil pe0aldub UP 1a£25,000 Wi Udy,U,,41 Iibr OLIdUUn Pm day ue deG011bbU Irl PUbIIC ROJCUI'CU Cd,Uo sCallCn 421u2. <br /> viCladan or uaminiaralivc purwUlo;111 10 40a)pa5, r vialulian pur day au dmI:211d'bi Public <br /> RJnUni Ce GCdr 8HCIU)11 42902. <br /> [ ] Imported Load [ J Exported Load and Location Hauler Exemption Status: <br /> Address' [ ] Government <br /> LEA Exempt <br /> • N, (D City: State: [ ] Agricultural <br /> 1 rllrrlmnn (ArriAr <br />