Laserfiche WebLink
D 10,1158 <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 �}�/ Z Q.� -�:./SCI �t" �✓ Load Date 165 <br /> Address ( � b `� TPID# <br /> City, State, Zips; Contact <br /> Phone# PO# <br /> No. Qty Tire Size P/F/S Tread Design/Labor R&R Disp RSN FI <br /> 2 411 <br /> 3 �i Z S� <br /> 4 u J�i �� '7 Z 13z5� <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> Set up Press Trailer[ V--service Call[ ] Unit# Hours <br /> Load Amount Load Type Lic # � dG <br /> [ ,hole VfTons ]Pounds Cubic Yards State California <br /> [V]Pickup [ ]Delivery Decal # O <br /> 11q-4-4 2-- <br /> Customer Name(Please Print) Cus r Signature <br /> ".1ify at under penalty of pe ury under the laws of the State of California <br /> that the information provided above is true and correct. <br /> -Date <br /> 1144 1 <br /> Driver's Name (Please Print) Driver's Signature <br /> °I certify,th �at <br /> r penalty of perjury under the laws of the State of California <br /> `� tc that the infor 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 /> ♦�nate Resource Code section 42960 and may result in civil penalties up to$25,000 <br /> 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 />