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d' <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 I? LO zl- 1 Load Date 4c% l Gam' <br /> Address �2/��J �Vj° �'/� TPID# 7 12/ <br /> City, State, Zip Contact <br /> Phone# PO# <br /> No. Qty Tire Size P/F/S Tread Design/Labor R&R Disp RSN �,% <br /> 2 <br /> 3 - <br /> 4 7/ 21 <br /> 5 <br /> 6 <br /> 7 7 z ' 1 Z--- <br /> g i l� 2_ "J✓ Z- <br /> r ( c{ 15- <br /> et up Press Trailer[ ] Service Call [ ] Unit# Hours <br /> Load Amount Lodd Type Lic # j'p Z <br /> �� ]Whole [ ons [ ]Pounds [ ]Cubic Yards State California <br /> [ Pickup[ ]Delivery Decal # <br /> Customer Name(Please Print) ' Y Cus er Signature <br /> "I certify that under penalty of pb4ury under the laws of the State of California <br /> that the information provided above is true and correct. <br /> D e <br /> Driver's N (Please Print) Driver's Signature <br /> rt <br /> fy that under penalty of perjury under the laws of the State of California <br /> at t the information provided above is true and correct. In addition, I am aware <br /> D e 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 I)at 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 /> W � <br /> CM <br /> iiv <br />