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E` <br /> J - <br /> ��. <br /> _. WORK ORDER/MANIFEST <br /> waste Tire Hauler 1274877- <br /> Mc oy Truck Tire <br /> Service Center, Inc. Waste Tire Generator <br /> 1407 Lone Palm Ave. Name: <br /> Modesto, CA 95351 Address: <br /> 209-521-6221 City: <br /> Load TPID 1274877-01 State: <br /> DDate: Zip: Phone: <br /> O TPID with <br /> Ca� Suffix# Load Type: ( ]Whole [ ] Cubic Yard <br /> License # j Ton [ ] Pound <br /> [ ] REGI State: Dot Code: RWDY )Pick-up Count: <br /> LAR TIME ( ) OVERTIME [ )CALL OUT CUSTOMER PO# <br /> FLAT REPgIRS _—_-- <br /> ----_ WHEEL SWITCHES <br /> LICENSE NO MT/DISMT <br /> LOCATION. VEHICLE MAKE MILEAGE <br /> VEHICLE NO._ <br /> f` WORK PERFORMED: <br /> I <br /> MILEAGE IN - <br /> MILEAGE OUT <br /> — - - - TOTAL <br /> TIME IN <br /> -- <br /> I '(: s31 TIME OUT <br /> SIZE_ MFG. DOT# TREAD WHEEL <br /> COMMENTS <br /> 3 — -- <br /> 1 <br /> 4 _ <br /> 6 -- <br /> r <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DA <br /> ,ivers Signature: Date: ' j: Customer Signature: Date: <br /> fivers Name (print) Customer Name (print) <br /> I certify that under penalty of perjury under the laws of the Slate of Calllomia that the information <br /> de that under penalty of perjury under the laws of the State of Californiaioo that the information may <br /> provided above is true and correct.In addition,I am aware that falsification of this information may <br /> ded above is true and correct.In addition,I am aware that falsification of this information ma <br /> t 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 s5,000 <br /> Public Resource Code section 42960 and may result in civil penalties up to$25,000 per day, per violation per day as described in Public Resource code section 42962. <br /> 3lati oodeasection t42962Penalties up to$5,000 per violation per day as desc bed in Public <br /> rce <br /> Date Waste Tire Delivery Point <br /> �rcepelivery Count: _ _ _ __ [ I Same AS Hauler <br /> Waste Tire Delivery Point Waste Tire Delivery Point <br /> �vORK ORDER/MANIFEST V�` �� [ ]McCoy Truck Tire Service Center [ ] McC1537E. Market St <br /> Tire Service Center <br /> 10850 Ha Ian Rd <br /> w` <br /> An-777 R Franrh Camn Ca 95231 Stockton (a Qr,)nr. <br />