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Waste Tire H.3L.,er Waste Tire Goner-Attar <br /> "CCOY,Truck 7- <br /> Nomo <br /> LOad Date: <br /> 0ecal # <br /> -- <br /> License 4: ]Pick-Lip C01,111t: <br /> RWDY <br /> I REGULAR TIME <br /> F CUS I 0KIFR,1`10itil <br /> FLAT REPAIRS. <br /> LICENSE NO VANLO Kill-FAGE VEHICLE- NO <br /> LOCATION: <br /> WORK PERFORMED: NIILEACE IN <br /> MILEAGE i--).lf <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG, TREAD WHEEL <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> R ;;O TO 100o MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 C <br /> RE-TORGUE LUG NUTS AF—� _-- <br /> Drivers Signature:! Date: Customer Signature: Date: <br /> Drivers Name (print) Customer Name (print) -s of vio stau,et cAiwomw that the intomatton <br /> me W"��,rt4 tr-at ine information I certify that under penalty of perjury under the iaN it <br /> talsAfi,�.,�AbOn 01 IN nm y <br /> I certify that under pe ami 7wsrk _.&nsmirormation may provided above is true and correct in addibon,I am aware that 5 Inlomiallo a <br /> c on or adnuntstratA,6 ponalties Up to S5,000 <br /> provided above i! 9 and correct.In addition. -iaL R w3bon pursuant result ch 11 penalties up to$25,000 per day,per v�olatk <br /> V '1� <br /> ;tru, jh, W 71(V, <br /> ion revocation,-denial a'ron— ler"I ay as descnbed in Public Resource cxxlo wt on result in suspension, Code section 429W and Mfi��mj� L,N-5.000 per day, per violation per d <br /> to the Public Resource I- 'sr-d sc desfit-odo Public <br /> iministrative Penalties UP to S5,3�lkl % <br /> per Code secfiw 42962 <br /> er violation or ac Waste Tire Delivery Point <br /> ]Delivery Count: Date Same As Hauler <br /> Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFEST [ )McCoy Truck Tire Service Center McCoy Truck Tire Service Centel <br /> 10850 Harlan Rd. 1537 E. Market St. <br />