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"Obdownffift No.- q'3 T2, <br /> 3005 Central Avenue TPID # 1574063-01 <br /> Ceres, CA 95307 Phone 209-537-4881 <br /> Visit us on our website at www.mccoysindustrialtire.com Fax 209-537-7388 <br /> Customer l , Load Date <br /> Address TPID# C � Z �5� (✓ <br /> City, State, Zip 4:a -k Contact <br /> Phone # PO # <br /> No. Qty Tire Size Tread Design P/F/S <br /> 2 <<- <br /> 3 y <br /> 4 <br /> 5 <br /> 6 <br /> 7 J <br /> 9 <br /> 10 <br /> X2/0 <br /> 12 <br /> Load Amount Load Type Lic # F 7 to 'Z <br /> L [ Whole Tires [ ]Tons [ Pounds ]Cubic Yards State Califor is _ <br /> LJPick up [ ]DeliveryDecal # t t"2 S <br /> (C- <br /> Customer Name(Please Print) C tomer Signature J <br /> "I certify that under-penalty of perjury under the laws of the State <br /> of California that the information provided above is true and <br /> Date correct. <br /> er's Name (Please Print) Driver's Signature <br /> "I cethat under penalty of perjury under the laws of the State <br /> of alifornia that the information provided above is true and <br /> 13at�r f Date correct. In addition, I am aware that falsification of this information <br /> wt�l ,91, may result in suspension, revocation, or denial of renewal of the <br /> Waste Tire Hauler Registration pursuant to Public Resource <br /> 41 <br /> Code section 42960 and may result in civil penalties up to <br /> GMiM <br /> $25,000 per day,per violation or administrative penalties up to <br /> $5,000 per violation per day as described in Public Resource <br /> Code section 42962." <br />