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-- "" - WORK ORDER/MANIFEST <br /> 1274877- <br /> waste Tire Hauler <br /> McCoy Truck TireWaste Tire Generator <br /> Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. <br /> Modesto, CA 95351 Address: <br /> 209-521-6221 City: State: <br /> TPID-1274877-01 Zip. Phone: <br /> Load Date. TPID with Suffix: <br /> Decal # Load Type: [ }..Whole [ ] Cubic Yard [ I Ton [ ] Pound <br /> License#: — —— — <br /> state: [ ]Pick-up Count: <br /> LAR T <br /> [ 1 REGULAR Dot code: RWDY .---�'� <br /> TIME [ i OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS -- <br /> --- WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. <br /> LOCATION: VEHICLE MAKE MILEAGE VEHICLE NO. <br /> tlVORK PERFORMED: <br /> MILEAGE I <br /> -- - MILEAGE OUT <br /> TOTAL <br /> ----- ------ --__.--. TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> --— <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DA` <br /> Drivers Signature: Date: Customer Signature: <br /> Date: <br /> Drivers Name (print) <br /> _.r. Customer Name (print) <br /> I certify that under penalty of Perjury under the laws of the State of California that the information I cervi that under penalty of <br /> certify P y Perjury under the laws of the State of California that the information <br /> provided above is We and correct.In addition,I am aware that falsification of this information may provided above is true and correct.In addition,I am aware that falsification of this information may <br /> result 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 u to$5,000 <br /> to the 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. P <br /> Per violation or administrative penalties up to$5,000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> [ Delivery Count: _+_ _ Date Waste Tire Delivery Point <br /> [ ]Same As Hauler <br /> o�cnaW p� Waste Tire Delivery Point Waste Tire Delivery <br /> WORK ORDER/MANIFEST [ ] McCoy Truck Tire Service Center S Point <br /> w � 10850 Harlan Rd. [ l McCoy Truck Tire Service Center <br /> 1274877- X. B French Cam Ca.95231 Stockton, <br /> to Market St. <br /> Camp, Stockton,Ca. 95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0 <br />