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m, <br /> is <br /> - <br /> _ JJORK ORDER MANIFEST <br /> 1274877- <br /> McCoy <br /> Waste Tire Hauler Waste Tire Generator <br /> Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. <br /> Modesto, CA 95351 Address: <br /> City: State: <br /> 209-521-6221 Zip: <br /> Zip: Phone: <br /> I-acid Date: TPID with Suffix: <br /> DeCa1 # Load Type: [ ]Whole [ ] Cubic Yard ( J Ton ( J Pound <br /> License##. —_— — [ Tick-up Count: <br /> State: Dot Code: RWDY <br /> ( ] REGULAR TIME [ ] OVERTIME [ ]CALL OUT CUSTOMER PO# <br /> FLAT REPAIRS - -_ WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. <br /> LOCATION: VEHICLE MAKE MILEAGE VEHICLE NO. <br /> WORK PERFORMED_ MILEAGE IN <br /> - -- MILEAGE OUT <br /> TOTAL <br /> TIME IN - <br /> w. TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 1 <br /> -- - ---------- <br /> 2 t. <br /> 3 <br /> 5 <br /> 6 <br /> 7 <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS LEFT OVER 30 DA <br /> Drivers Signature: Date: 1. Customer Signature: Date: <br /> Drivers Name (print) , ; ;, Customer Name (print) <br /> �rtfiy that under penalty of peritxy eget the Laws of the state of California that the information I candy that under penalty of pequry under the laws of the state of Catfomia that the information <br /> )rovided above is true and correct-In addition,I am aware that falsification of this information may prorded above is true and oorrecl.In addition,I am aware that falsification of this information may <br /> esu in suspension•re"or ation•a do"of renewal of the Waste Tire Hauler Registration pursuant res.A civil penalties up to$25,000 per day,per v olation or administrative penalties up to$5.000 <br /> o the Public Resource Code section 42980 and may result in civil penalties up to 525.000 per day, per violation per day as described con Public Resource Code section 42962. <br /> ,er violation a admirtm"tive pennies up to 55,000 per violation per day as described in Public <br /> resource Cala—,lion 42962. <br /> i ` Waste Tire Delivery Point <br /> ]Delivery Count: ____ Date [ �Same As Hauler <br /> tDA4 r Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER 1 MANIFEST [ j McCoy Truck Tire Service Center [ )McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> I 07A A77-C (i I;Z Al 1B French Camp, Ca.95231 Stncktnn rn or:,)nr <br />