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- _� . _ <br /> 3005 Central Avenge• Ceres, CRS015307 TPID* 1.574063-01 <br /> a i <br /> Visit us on our website, at www.mccoysindu&trialtire.com P 409-537-4881 <br /> Customer eN& <br /> Load Date <br /> Addrass D 3 <br /> z. TPID# <br /> City. State, Zia Contact I' <br /> Phone# PO # <br /> 4 <br /> Qts' Tire Size RT/S Tread Design/Labor R&R Disp RSAr FZ <br /> 2 �� <br /> 3 <br /> b <br /> Sat UP Press Traile ] Service Calf ( j Unit# Hours <br /> j <br /> Lzad Amount Load Type Lic # <br /> [ hole JTons Pounds ( Cubic Yards St to Cal mi�j <br /> Pick up ( 1Delive Decd # b <br /> i <br /> Cust mer N e( lease print; Customer Signature <br /> `I csrtlfy that under penalty of perjury under the laws of the St$ts of California <br /> that the information provided above is true and correct. <br /> Date <br /> lust`s N the ( ease Print Drives <br /> "I certify that der penalty of perjury under the laws of the State of California <br /> that the info tion provided above is true and carr-act. In addition, I err aware <br /> to that taisification of this inf6rrration may result in suspension,revocation,or <br /> d6)16 of renewal of the.Waste Tire Hauler ReQl5trstion pursuant W Public <br /> c bats Resource Code section 42960 and may result In c)vli penaities up to SMDO0 <br /> per day; par violation or administrative penalties up to S5,0M par vi6latiorr per <br /> `:•.;riay es describetl in Public Resource Colic aeCtiofi 42952.' <br />