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P, <br /> 3005 Centra( Avenue w TPID# 1S74063-01 <br /> CeFes, CA 95307 Phone 209-5374$81 <br /> Visit tis on our website at www.mccoysindu-;trialtire.com Fax 205-537-7388 <br /> Custbmer 4 Load Date t <br /> Address.,- TPfD# <br /> 7 0( . <br /> City,:5'fate, Zip Contact <br /> Phone # P(D # <br /> No. Qry Tire Size Tread Design P/F/S <br /> 2 Cs <br /> - <br /> i:. <br /> 4 ' <br /> 7 <br /> r A,, <br /> 8 <br /> S <br /> 10 <br /> 12 f` <br /> Load Amplint 6,ad i ype LIC # /72_,2 <br /> [ <br /> /Ihobe Tires [ ons L JPoLinds ]Cubic Yards State Caiiiorr ^ <br /> -[pick up [ Deiive De �j <br /> Customer Name(Please Print) GSigna <br /> 6t certify that under penalty orf perjury under the laws of the Skate <br /> of Cal ifom that the Inf nnati rOVided above is true and <br /> Dat carr <br /> Cs Name (Please Print) Driver`s Signature <br /> "I certify t at under penalty of perjun under the laws of the State <br /> of Cal- rnia that the inforrnation provided above Is true and <br /> a, c 'Date. - correct addition, I am aware that fbisincafion of ibis informatior <br /> 1 may result in suspension, revocation,or denial of renewal of the <br /> Waste Tire fdauier Registration pursuantta Public Resource <br /> Code sacfion 42960 and may result in civil pena{ties up to <br /> S25,000 per-daj,-per v}olation or administrative penalties up to <br /> S5,000 par violation par day as described in Pubfit.Aesburce <br /> Code section 42862." ; <br />