Laserfiche WebLink
IMP <br /> 3005'CGTltrdl Avenue. TPID # 1574063=01 {` <br /> Ceres, CA 95307 Mom 209-537-4881 <br /> Visit us on our website at www:mcxoysi'ndustrialtire.aom Fax 209-537-7388 <br /> y, <br /> Customer' Load Date I <br /> 'Address `7(� 6l e!��aa �4--( TPI D# I <br /> City, State, Zip Contact <br /> Phone # PO # <br /> No. Qty Tire Size Tread Desi PIF/S <br /> 3 Y <br /> 4 4 Z ! <br /> 5 /L_ <br /> 6 L � ee&4?- ski <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 �o S,- toy", <br /> r <br /> Ll 2 Z-(Z <br /> Load Amount Load Type I_fC # p <br /> JdvWtiolle Tires [ Tons Pounds Cubic Yards State California <br /> Pick u ]Delivery Decal # cwo <br /> Customer Name(Piesse Print} us6omer e <br /> `I certify thd4er penalty of pedury under the laws of the State <br /> of California that the information provided above is true and <br /> Date correct. <br /> Driver's Name(Please Print) Driver's Srgnature <br /> "I car*(fiat or penalty of perjury under the laws of the State <br /> of Califon that the information provided above is true and <br /> Tf Date correct.in dition.I am aware that falstflcetion of this information <br /> may resu in suspension, revocation,or dentsl of renewal ofths <br /> Waste Tire Hauler Registration pursuant to Public Resourop;• - <br /> M Code section 42960 and may result in civil penalties up 6b;' <br /> r 1251oQ0 per day,per violation or'administrative penalties up to, <br /> .r�. $5,000 per violation per day as dwcMaa in Pub ie Resource <br /> Code section 42962.". <br /> ' 'i`' <br />