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i. <br /> offWORK ORDER/MANIFEST <br /> 1274877- <br /> Waste Tire Hauler Waste Tire Generator <br /> McCoy Truck Tire Service Center, Inc. Name: <br /> 1407 Lone Palm Ave. <br /> Address: <br /> Modesto, CA 95351 City: State: <br /> 209-521-6221ZiPhone: <br /> TPID-1274877-01 p: <br /> I-.oad Date TPID with Suffix: <br /> Decal # Load Type [ ]Whole [ ] Cubic Yard [ ]Ton ( ] Pound <br /> License #: .___ — — — [ ]Pick-up Count: <br /> State: Dot Code RWDY <br /> I ] REGULAR TIME [ ] OVERTIME [ j CALL OUT CUSTOMER PO# <br /> LAT REPAIRS WHEEL SWITCHES MT/DISMT <br /> LICENSE NO. <br /> _ <br /> LOCATION: VEHICLE MAKE MILEAGE 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 /> 2 - - - - <br /> t - <br /> 3 <br /> 4 ] �i <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: ` /; Customer Signature. Date: <br /> Drivers Name (print) Customer Name (print) <br /> certify that under penalty of perjury under the laws of the State of California that the information I certify that under penalty of pequry under the laws of the State of california that the information <br /> xovided above is true and correct.In addition.I am aware that falsification of this information may provided above is We and correct.In addition.1 am aware that falsification of this information may <br /> esus in suspension.revocation.or denial of renewal of the Waste Tire Hauler Registration pursuant result civil penalties up to 525,000 per day,per violation or administrative penalties up to s5,000 <br /> a 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 /> ,er violation or admirusuative penalties up to 55,000 per violation per day as described in Pubic <br /> tescurce code section 42962 <br /> [ ]Delivery Count: Date /f t- 1 ! Waste Tire Delivery Point <br /> —— ——— [ ]Same As Hauler <br /> tiara r Waste Tire Delivery Point Waste Tire Delivery Point <br /> WORK ORDER/MANIFESTS [ ]McCoy Truck Tire Service Center [ ]McCoy Truck Tire Service Center <br /> 10850 Harlan Rd. 1537 E. Market St. <br /> �7A q77- •`'`• k '� B French Camp, Ca. 95231 Stnrktnn r.m ozone <br />