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3005 Central AVenue Ceres, CA 45307 TPID # 1574063-01 <br /> 0,41: us on our website at www-mccoysindustrialdre.com P 209-537-4881 <br /> Customer fi/!�✓�� , �J� Load Date <br /> Address _9-D ! TPID# <br /> City, State. DPL,6*�,g Contact <br /> Phone # <br /> PO# <br /> No, Qt' Tire Size P/R/S Tread Design/Labor R&R DISP RSN FI <br /> 2 -2, <br /> 3 <br /> L4 <br /> 5 <br /> b , <br /> !7 <br /> I <br /> I <br /> f <br /> 9 <br /> Set up Fress Traller(Service Call [ ] Unit# 70' y Hours <br /> Load Amount `Load Type LiC g L e- <br /> Whole ]Tons ( lRounds [ ]Cubic Yards State California <br /> ]Pickup Delivery ecal # 0 <br /> Customer NernB(Piease Print) C�OrnarSigna-Tu—r& <br /> 1 certffy that under penalty of perjury under the isws of the State of California <br /> that the information provided above is true and corracL <br /> ��l ate <br /> F�T•<r. <br /> Drivers game (Please Print) DCNef's Signature <br /> "I osrtifylorTnabor <br /> t under penalty of perjury under the iavvs of the Stair;or california <br /> that the provided above is true and correcL in addition, I am aware <br /> Date that taisification of this information may result in suspension, revocation, or <br /> denial of renewal of the Waste isre Hauler Registration pursuant to Public <br /> Resource Coda section 42960 and may result in eivii penalties up to$25.000 <br /> per day, per violation or administrative penattles up to s 0100 per violation pe <br /> v day as dascrlbad in Public Resource Code section 42962.' <br />