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WORK ORDER!AIANIFE <br /> 1274877- <br /> Sj <br /> Waste Tire Hauler <br /> McCoy Truck Tire Waste Tire Generator <br /> Service Center, Inc. <br /> 1407 Lone PalmName: <br /> Modesto, Ave. Address: <br /> CA 95351 <br /> 209-521-6221 zip. State: <br /> Load Date: <br /> TPID-1274877-01 IpPhone: <br /> TPID with Suffix: <br /> Decal ## Load Type: [ ]Whole [ ] Cubic Yard [ ]Ton [ ] Pound <br /> License#; <br /> State: Dot Code: RWDY ]Pick-up Count: <br /> [ ] REGULAR TIME <br /> [ ] OVERTIME [ ] CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS _------_--- <br /> -----_ WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. <br /> LOCATION: VEHICLE MAKE MILEAGE VEHICLE NO. <br /> .WORK PERFORMED: <br /> - MILEAGE IN <br /> MILEAGE OUT <br /> - - TOTAL <br /> ------ TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> - <br /> 1 _ - <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 D, <br /> Drivers Signature;," ""` Date: Customer Signature: Date: <br /> Drivers Name (print) ;1 10 Customer Name (print) <br /> I certify that under penalty of penury under the laws of the State of California that the information I certify that under penalty of perjury under the laws of the State of California that the information <br /> provided above is true 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 525,000 per day,per violation or administrative penalt es up 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. <br /> per violation or administrative penalties up to$5,000 per violation per day as described in Public <br /> Resource Code section 42962. <br /> ��� �� �� Waste Tire Delivery Point <br /> Date C ]Delivery Count: —__ _ ( ) Same As Hauler <br /> C.Datgp� Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST �� [ ],McCoy Truck Tire Service Center ( ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> 1274877- 0 r� 3 6B French Camp,Ca. 95231 Stockton, Ca. 95205 <br /> o lr TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-65; <br />