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WORK ORDER <br /> waste Tire - -- ----- - - 1274877- A <br /> Hauler <br /> Jr� I r,U.k Tirr _ Waste Tire Generator <br /> x:r�l1;r: (;r�ntr:r, Iter. <br /> 1407 Lgnr• f'.,Irrf Avo Name: <br /> Mc,r1r, tr,, CA y;"i.';1 Address: <br /> 209-x,21-6221 City: State: <br /> Load Date TPID-127487/-(i1 Zip. Phone: <br /> TPID with Suffix: <br /> Decal # '-()a(] f ypr; ( ) Whole [ ] Cubic Yard ( ] <br /> LlcenSe on Pound <br /> T ( ) <br /> � - ____ <br /> ( l REGULAR TIME State Dot Code: RWDY L ]Pick-up Count: <br /> ( ] OVERTIME [ J CALL OUT CUSTOMER PO# _ <br /> FLAT REPAIRS_ 1/,/t-{EEL SWITCHES—— tAT/DISMT <br /> LICENSE NO. <br /> MILEAGE <br /> LOCATIOtj VEHICLE MAKE- 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 /> TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 <br /> rs Signature: Date: Customer Signature: Date: <br /> rs Name (print) Customer Name (print) <br /> -at under penal^,/cf perjur,/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 infom,aticn <br /> above is true and orwres-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 mai <br /> uspension,revora4on,or denial of renewal of the waste Tire Hauler Registration pursuant result civil penalties up to$25,000 per day,per violation or administrativepenalties up to S-5 <br /> tic Resource Cade w—jon 42850 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 /> in or administratie penatties up to$5,000 per vioiation per day as described in Public <br /> Code section 42992. <br /> Waste Tire Delivery Point <br /> ►elivery Count: — _ _ ._ _ Date [ ] Same As Hauler <br /> �c pard p Waste Tire Delivery Point Waste Tire Delivery Paint <br /> )RK ORDER I MANIFEST �� ( ] McCoy Truck Tire Service Center [ ] McCoy Truck Tire Service Ceni <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> 877- B LQ French Camp, Ca. 95231 Stockton, Ca. 95205 <br /> TPID #1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone '_'d< <br />