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Frow 0 <br /> sI <br /> lop <br /> II It�rnnl In I . <br /> :� w•II,I I it A <br /> I, � , <br /> Wasto flro I I:rfflo, Waste Tire Generator - <br /> McCoy TrIICh I lilt.`lnlvlrt+e ,,nl 'I Inr Name: <br /> 1,107 1 om,I';iIm AV,, Address: <br /> Motlusl,,,t IA Il!,tl,l City: <br /> :t09 I I,,.,I <br /> Zip: _----" <br /> TPIID E., 11l TPID with Suffix: — <br /> ----- Cubic Yard [ �Ton [ ]Pound <br /> Load Date: I ttnd lyptl [ ]Whole [ ) <br /> Decal # — [ ]Pick-up Count: <br /> —--- - ;tai„ Dot Code: RW DY _-- <br /> License#: <br /> [ ]REGULAR TIME I I <br /> ()VI I:1 IMI--: I I CALL OUT CUSTOMER P --- <br /> MTIDISMT -__ <br /> FLAT REPAIRS_—_-_-__ WIIII`I SWITCHES ___ - , <br /> MILEAGE VEHICLE NO <br /> LICENSE NO.—__—. `VEHICLE MAKE ---- <br /> LOCATION. MILEAGE IN <br /> WORK PERFORMED MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> WHEEL COMMENTS <br /> SIZE MFG DOT tt _ TREADL <br /> 2 ---------- -- -- -- <br /> 3 --- — - -- <br /> 6 - -- - <br /> 7 <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DAYS <br /> Date: i <br /> 7 r,; Customer Signature: Date: <br /> i' I ' <br /> Drivers Signature: <br /> (`) Customer Name(print) i the __ <br /> Drivers Name(print) <br /> In addition.I am awero that falsification of In,s�ntormatan may <br /> I comfy that un penalty of penury undor'he <br /> Inwx of Ilio state of CaLforma Thal the Information Certify that under penalty of perjury under NerlwGl�uon or�mmisVal vtate of apa wia attles up Io 55.000 <br /> tg ursuant resull civil penalties up to 525.000 per day,po <br /> r violation per da as de5cnbed m Public Resource Code section 42962 <br /> provided above a True end wrmct.In ntldol,u,, ora awuro Ilial to it alion ll tMs informal strbn may prodded above is t Y e an m <br /> result in suspans1on,revocation,or danlul of rnaewayl nlr v o al onepor dey a9 de is in <br /> ubllc <br /> tppo Ilio Puhlic Resource Code secnlalllae u6Otd'S5 000 fo ull In civil penalties up to 25.000 per day. per <br /> Rosource,Codaasorcabin 4296 G Waste Tire Delivery Point <br /> €, Date [ ]Same As Hauler <br /> [ )Delivery Count: -- <br /> Waste Tire Delivery Point <br /> d�pa� Waste Tire Delivery Point <br /> �, °a Truck Tire Service Center ( ]McCoy Truck Tire Service Center <br /> [ ]McCoy 1537 E.Market St. <br /> WORK ORDER I MANIFEST �g 10850 Harlan Rd. Stockton,Ca.95205 <br /> B French Camp,Ca.95231 <br /> :.� <br /> 1274877 French <br /> h 352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />