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fill'it <br /> _7 1 <br /> - - 1274877- <br /> V'V"`te Tire <br /> Waste Tire Generator <br /> Name: <br /> _ Address. <br /> City: State. <br /> Zip: Phone: <br /> -- TPID with Suffix: <br /> Cal _ ( [Cubic Yard ( ]Ton ( ] Pound <br /> -- — RWDY ]Pick-up Count: <br /> :. <br /> -i\,'E IJSTOMER PO## <br /> - MT/DISMT <br /> MILEAGE <br /> VEHICLE NO. <br /> MILEAGE IN <br /> - MILEAGE OUT <br /> . TOTAL -—- <br /> TIME IN <br /> TIME OUT <br /> MFG. DC' to/I IEEE COMMENTS <br /> i <br /> I <br /> •TORGUE LUG NUTS AFTER PAll_E=S -- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DAYS <br /> -s Signature' ;- _- Custorner Signature: Data: <br /> Name(print) Customer Name (print) <br /> y_xner.9e`. c'pequr}'undeer Ine:aws of Me 510116�t'�alf,•r•+a t, .:•n r,farrowm I(entry,Thal under penalty of perjury under the laws of the State of CaVomia that the nkirmxn n <br /> t vve rs t ue and axrec: In aderwn.i am aware na•.faredr alio• V 1•,,; (nq•/ provided above Is true and corroct.In addition,I am aware that faisi icawn of this mfomatt o ni'm <br /> ,sw ;e4cabm.or deruai of renewal of the Waste lrr6 ,,,,tcr t•.w halmw.i�pw4oanf rakull civil psnalllaa up to$25.000 per day,per violation or admmstnbve penalties tip to$5.Lx\) <br /> R.es,axCe C�s:,e section 4296`0 and may result in C-0,;rt+oatla+e.+:,•: ?:",rl,pat day, per violelion per day as described in Public Resource Code section 42962. <br /> n x g� ,bes up to$5.6Jo per✓ioiaUcrer 1•;ptic'..w/r.:r,n PoNlr, <br /> ids se¢-r`25F_' <br /> Waste Tina Delivery Point <br /> ►elivery Count: — _ _ _ Date ( ]Same As Hauler <br /> r 44;r Wl to Tire Delivery Point Waste Tire Delivery Point <br /> IRK ORDER i MANIFEST Ah(;(;oy rruck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> it 850 Harlan Rd. 1537 E. Market St. <br /> B F`ronch Camp, Ca.95231 Stockton,Ca-95205 <br /> 877 rvir.)#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-0434 <br />