|
I
<br /> 1274877
<br /> r
<br /> M, Waste Tire HaUfAr ------
<br /> {'llv toch nr -
<br /> e Sr,,.,,.,, , Waste Tire Generator
<br /> 1407 Lane
<br /> Modesto, CA -
<br /> 209-521 ii' t;atr
<br /> It 12�agr/;
<br /> torn `,uffv
<br /> NC, # --
<br /> l.li•t, _-
<br /> ( I Rt c;l{1 state - [ ]Pick-up Count:
<br /> AR TIME -- € 41 DY
<br /> I 1 OVERTIDGe.
<br /> FLAT REPAIRS
<br /> LICENsE NO WHEEL S`//l;r '= '• —
<br /> t!• If•
<br /> LOCATION: VEHtGt tri;
<br /> ! r"r'r VEHICLE Nr)
<br /> ORK PERFORMED:
<br /> I _
<br /> — T t.tE
<br /> SIZE --
<br /> 1 MFG. DOT tt
<br /> C
<br /> 2
<br /> i
<br /> � I
<br /> 4
<br /> 7
<br /> RE-TORGUE LUG NUTS AFTEP ,r, ff, ?t,C; 1AIf I Nor RESPONSIBLE FOR GOODS LEF1 C)V[-;4
<br /> Drivers Signature: bats) y t,{, t{3mrtr Sgnature: r
<br /> Divers Name (print) /,I�Ztr"rnvr Narne(print)
<br /> ...-, . _
<br /> •.ertrl'y that under penalty of perjury under the laws of IY,e state rf r.a 1Y,7e W M�.+R✓�a,k. a.ar w,00,(.amity
<br /> Xv++drr>>above is true and correct.In addition,1 am aware that lsitsrfirrf,c n rA rh♦rr,.,..,,.;.,r s Va+h"f un.7p tAe irwn of cw S.OaW M Gagkvn,r D+el x,e s,1;,,w,*S�r
<br /> / J Wr.,.r y bt.e rrvJ a"viwl {n rdCNO,M;,I rm
<br /> rcputt in suaperroron.revocation,or dental or renewal of thr•N/rs}e!re HMde+N wv'ir.��... a OOL °'"°r's that SMaihCMn+.W m+a•,Ra•+.emn>r„4:w
<br /> t;Vie Public Resource Code section 42980 and may result in rAw pennei,*4 ,,.. ;4 v/Ir w r r "N4.61, 43 s'K )iri dot.par iry C 4 rdrtwerbytw tw!rhp K.c.t',,#y.
<br /> W P P yper virdatren M in
<br /> on--I• na. / '�" tsr,Say ao Aavart»tl,n PutW:.Rwwuna C[dr srclky+l24Ui
<br /> rxha�on or adm,nislrativa penalties u to SS.000 per Any
<br /> Raovr•:e CMe section 42962
<br /> ( ]Delivery Count: _ _ _.�. �•..DRW aste Tins Delivery py ftr
<br /> Same As Hauler
<br /> I �;,c Dw*p� I� 0440 fifty 1,4e11vefy Point
<br /> ✓dORK ORDER/MANIFEST 3 i I lkf,,,f t rui;k lira Service Center Waste Tire k lite p{"nr
<br /> SJ;aytr,11aftiart ltd. I �McCoy Truck Ttre Servts�(.k+;►pr
<br /> 1274877- 0 5 0 71 B c rktwlx GamtrtStocktoo
<br /> p,Ca 95231 tMarket 51
<br /> Stocn,Ca 952(15
<br /> (1116 A1:16-2WA-J1 Phone 209-982-0115 TPID#1778978-U1 pttw*
<br />
|