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N9 1092 i <br /> 3005 Central Avenue Ceres, CA 95307 TPID # 1574063-01 <br /> Visit us on our website at www.mccoysindustrialtire.com P 209-537-4881 <br /> Customer Nle F,;`eI-" Load Date ZS <br /> Address 6 D C .CiV2,%7 TPID# l7 yl` <br /> City, State,Zip Contact <br /> Phone# PO# <br /> No. Qty Tire Size P/F/S Tread Design/Labor R&R Disp RSN FI <br /> Z' z <br /> 4 L <br /> 7 16 <br /> Set up Press Trailer[1u]�Service Call [ ) ��it Hours <br /> Load Amount Load Type Lic # � ��t,2 <br /> [ toe Tons [ ]Pounds [ ]Cubic Yards State Califor is <br /> [ Pick up [ ]DeliveryDecal # 7E ,?— <br /> J o R. <br /> Customer Name(Please Print) ustom Signature <br /> "I certi under penal of perjury nder the laws of the State of California <br /> that the informatio vided above is true and correct. <br /> Driver's Name(Please Print) Driver's Signature <br /> "I certify that under penalty of perjury under the laws of the State of California <br /> that the information provided above is true and correct. In addition, I am aware <br /> Date that falsification of this information may result in suspension,revocation,or <br /> denial of renewal of the Waste Tire Hauler Registration pursuant to Public <br /> �c 1)at,� Resource Code section 42960 and may result in civil penalties up to$25,000 <br /> �o per day,per violation or administrative penalties up to$5,000 per violation per <br /> '�� day as described in Public Resource Code section 42962." <br />