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_ _ - <br /> i <br /> _ ® WORK ORDER 1 M1IANIFES7 <br /> Waste Tire Hauler 1274877- <br /> McCoy Truck TireService Center, Inc. Waste Tire Generator <br /> 1407 Lone Palm Ave. Name: <br /> Modesto, CA 95351 Address: <br /> 209-521-6221 City: State: <br /> Load pate: <br /> TPID-1274877-01 zip. Phone: <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 /> VEHICLE MAKE MILEAGE VEHICLE NO. <br /> LOCATION: <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 /> SIZE --- - <br /> 1 <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 D, <br /> Drivers Signature:;' Date: Customer Signature: Date: <br /> Drivers Name (print) ^ -1t: Customer Name (print) <br /> 1 certify that under penalty of perjury 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$25,000 per day,per violation or administrative penalties up to S5,000 <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 /> .— <br /> ]Delivery <br /> Count: i Date f [ ]Same As Hauler <br /> [ +._._ _ <br /> Qar,pa4 Thd 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 /> �7_ B French Camp, Ca.95231 Stockton,Ca.95205 <br /> 487/ t TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-65; <br /> 127 ,..� _. � s <br />