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"W"M , _.. _,. No.� 94 5 <br /> 3005 Central Avenue TPID # 1574063-01 <br /> Ceres, CA 95307 Phone 209-537-¢gel <br /> Visit us on our website at www.mccoysindLlstr]altire.corn Fax 209-537-7388 <br /> t! <br /> Customer ! - Q�j toad Date 1 <br /> Address <br /> City, State, Zi <br /> Contact <br /> Phone # PO # <br /> Iia. Qty Tire Size Tread Desliml P/F/S <br /> 2 <br /> s >� <br /> 4 <br /> 5 <br /> V. <br /> 6 <br /> � 1 <br /> 12 <br /> Lead Amount Load Type Lic # <br /> 7- <br /> ]Whole Tires r its [ ]Pounds Cubic Yards stag Caiifo <br /> ��✓ ick, up )Dejilvery Decal # <br /> Customer Name(Please Prlrt) Customer i nature <br /> 9 <br /> .'I rettlfy that under pan of perjury under the laws of the State <br /> of Galifomla tha information provided above is true and <br /> e nDat rrect. <br /> Drivers Name (Please Print:) Driver's Signature <br /> "1 oerbfy t undsr panalty of perjury under the laws of the State <br /> of California that the information provided above is true and <br /> VZ Date �h Date correct•in addition, I am aware that faisrtcation of this lnformation <br /> ,t may resuR in suspension revocation, or denial of renewaha the <br /> `r Weate Tire Hauler Registration pursuant to Public Resource <br /> Code$action 42960•.Ot d may result in civil penalties up to <br /> $25,000 per day, per yia.'l8tIDr)or administrative penalties up to <br /> 35,DDO oar vioiation per day as described in Public Reaourc e <br /> .. CoCe section 42962.0 <br />