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46& 1W <br /> wnRK0,11ullrlln�lllll I <br /> 1274877- 5064 <br /> W.t-,to 1 it r I1•tulol. W,t .Il liar Gt ncl star / <br /> V, <br /> li'll� I."SFir'�-01 II'll)wllll ;lulli4 <br /> l x'•1:1 D,ur -- -- - ---- - <br /> L0.u1 1%,po I J Wholr I I c'uhh 1,u1,1 I I loll [ I Paunrl <br /> Del.11 # -- <br /> Llrt'nse-, — — — — - � �hlCk-l1I) �.(�lll)t: <br /> SLIto Dot 1001,10. RWDY --- <br /> [ J RE61.11-1R TINE [ ] OVERTIME [ J CALL OUT CUSTOMER PO!! - --— <br /> FLAT REPAIRS <br /> WHEEL SWITCHES Ntl' DISP:IT <br /> LICENSE NO VEHICLE MAKE MILEAGE VEHICLE NO. <br /> LOCATION <br /> WORK PERFORMED MILEAGE IN <br /> MILEAGE OUT <br /> TOTAL <br /> TIME IN <br /> TIME OUT <br /> SIZE MFG. DOT# TREAD WHEEL COMMENTS <br /> 3 <br /> 4 <br /> i <br /> 5 <br /> 6 <br /> 7 <br /> RE-TORGUE LUG NUTS AFTER 50 TO 100 MILES --- NOT RESPONSIBLE FOR GOODS Ll--:= OVER 30 DAYS <br /> Drivers Signature: Date: Customer Signature: Date: <br /> Drivers Name(pent) Customer Name(print) <br /> Icertify font under penalty of pegury under the laws of the State of California that the information I certify that under penally of penury urcl^•Ir r:I.i.,' - - - <br /> provided above Is true aril comect In addition,I am aware that falsification of this information may provided above is true and ccrrect In c C zn. <br /> result In suspenson,revocation.or denial of renewal o1 the Waste Tire Hauler Registration pursuant result civil penalties up to$25.000 per day,pe• - <br /> to Ile Public Resource Code Becton 42960 and may result,n civil penalties up to$25.000 per day, per relation per day as descnbed,n Pub:c Resp„ <br /> per=Wri or admlmetmtive penalties up to$5,000 per violation par day ns deccnbed,n Public <br /> Rasource Code section 42962. <br /> ]D�e�IVe Count: Date Waste Tire Delivery Point <br /> elivery ————— [ ]Same As Hauler <br /> �cDeW p� Waste Tire Delivery Point Waste Tire D _ <br /> WORK ORDER/MANIFEST ]McCoy Truck Tire Service Center I 1 McCoy Truck- Se " <br /> 10850 Harlan Rd 1537 E.Marke:S <br /> • 1274877- B French Camp,Ca.95231 Stockton,Ca.952, - <br /> and At, i• `` TPID#1352986-01 Phone 209-982-0115 TPID#1778978 <br />