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R. ORDER/MANIFEST <br /> 0 D r rrn,A / %— 0:1)0-1, it' 'Irr <br /> d. <br /> Waste Tire Hauler Waste Tire (Generator <br /> McCoy Truck."fire.Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. Address: j �, :.t.\.I_: �;tJ(7 � , �i� `,i ��',• <br /> Modesto, CA 96351 City:.Y.,��`,,; ��=;,r~;1t State: <br /> 209-521-6221 Zip:�j', ;;�t Phone:' .1 <br /> TPID-127487701 TPID with Suffix ; 7t � „��` C) <br /> Load Date:1;, Load Type: [/L] Whole [ ] Cubic Yard ( ]Ton [ ] found <br /> Decal # '; ? [ ] PicK-'Up Count, — <br /> License #:1 :�q. �r l State:,,. Dot"Code: RWDY [ ]. Delivery Count, — <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 v.�'J 1 Ci�\rt`• h L1 �. tom;`��C.-..� � �r� ��--•, <br /> 2 ., <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 /> ;;: Customer Signature: Date: <br /> Drivers Signature74,jr • �- ';�-- Date��-;:?` '� �'.-r `;' - n <br /> Drivers N , .. 11111. <br /> , - .. . .,._._-. ....... .. <br /> ame (pr0t) ) ;'` �� t �`,I� - Customer Name (print) �.,,`„- ; F <br /> I r7nlly that undor penally of paFrury unJur the laws of uw 51clo at Calliornia(hot IN hilorrnallon I corllly that under penally of oriury Mar{ho Me of the Stoto a,Cataomla ME the iNoomnlron ' <br /> urovidud abovu It;frau and con0ct.In pdollion,I am awdra tlml lublllwiluit of dtlu inlorinutfon may provldud ubavu is trua and corroci.In udditlon,I um uwdra Wal Idlurticatlon pf,thlu Inforriqlion may <br /> roa1111 i0 eus0enelWS,revowdai,ur dauial ul rurww8l Of ttm Wa610 Tlra HuUlor l9o0l�tration puimom ietiull In civil poiIalile6 tip to 925,000 Dei day.pei violation Or adndn1wauve pOrfSaI zg 0 6',000 <br /> to Public A�aaumu Cada caglan 1.1080 and may ruuuh in civil parcahlun up to 226,000 put day,par pur vloluliaa pur auy uc dosaribad In Public AUUDurGu Cudu uucllun ABAGe, <br /> vlul8pun ur hidinlnlevullva pdnalkldp up to 95,OOQ peJplolatlon par day oe,0uxrluod In Public <br /> Acisourcu Codii ai mdcn a.nnz <br /> [ ] Imported Load [ ] Exported Load and Location Hauler Exemption Status: <br /> C.DCtQ�r Address: [ ] Government <br /> v [ ] LEA Exempt <br /> m City: State: [ ] Agricultural <br />