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1274877- <br /> Waste Tire Hauler <br /> Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. <br /> 1407 Lone Palm Ave. Name: <br /> Address: <br /> Modesto, CA 95351 <br /> City: Slate: <br /> 209-521-6221 <br /> TPI D-1274877-01 Zip: Phone: <br /> Date: TPID with Suffix: <br /> al <br /> # Load Type: [ J Whole [ ] Cubic Yard [ ]Ton ( ] Pound <br /> 'e #. State: Dot Code: RWDY ]Pick-up Count: — <br /> _GULAR TIME [ ] OVERTIME [ ) CALL OUT CUSTOMER PO# <br /> REPAIRS WHEEL SWITCHES MT/DISMT <br /> JSE NO. VEHICLE MAKE MILEAGE VEHICLE NO. <br /> .TION: <br /> < PERFORMED: MILEAGE IN <br /> MILEAGE OUT <br /> TOTAL _ <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS -_ <br /> h <br /> �- z <br /> ORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DAY <br /> Signature: Date: Customer Signature: Date: <br /> Vame (print) Customer Name (print) <br /> '4 pLnatty r perjury under the laws of the Slate of Califomia that the information I certify that under penalty of perjury under the laws of the State of California that the information <br /> e is rie and cored.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 /> snsion,revocation,or denial of renewal of the waste Tire Hauler Registration pursuant peruviolat vlt civil iolationperies stdes2aibed 000 m Publer ic Resoer nate Code sectionn or 42962tive penatties up to$5,000 <br /> resource Code section 42960 and may result in civil penalties up to$25,000 per da p y <br /> r ad,7!r native penaltles up to$5,000 per violation per day as described in Public <br /> sermon 42962. Waste Tire Delivery Point <br /> livery Count: __- - - Date [ ] Same As Hauler <br /> c,pata p Waste Tire Delivery Point Waste Tire Delivery Point <br /> K ORDER MANIFEST <br /> 00 rd McCoy Truck Tire Service Center [ ] McCoy Truck Tire Service Center <br /> / S <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> i77- B French Camp, Ca. 95231 Stockton, Ca. 95205 <br /> TPID#1352986-01 Phone 209-982-0115 TPID#1778978-01 Phone 209-652-04 <br />