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��i��5(t3t1IICN U l�I I� N o. . [�q <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 1 t Load Date 7 7 <br /> Address 15!Dc,�Cj 61J, v TPID# - �u �Q <br /> City, State, Zip t C t�, _ 2n Contact <br /> Phone # PO # <br /> No. Qty Tire Size Tread Design P/F/S <br /> / v <br /> ell <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 - <br /> 10 <br /> I <br /> 11 <br /> C <br /> Load Amount Load Type Lic # <br /> 2 [UWhole Tires [ ]To 2t [ ]Pounds ]Cubic Yards State California <br /> [ ck u ]Delivery Decal # Z 0 Z� <br /> Customer Name(Please Print) Customer Signature <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 /> Driver's Name (Please Print) Driver's Signature <br /> "I certif/ha t under penalty of perjury under the laws of the State <br /> of Crnia that the information provided above is true and <br /> ` ai <br /> + 1) t<1 Date correct. In addition, I am aware that falsification of this information <br /> may result in suspension, revocation,or denial of renewal of the <br /> r� Waste Tire Hauler Registration pursuant to Public Resource <br /> Code section 42960 and may result in civil penalties up to <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 />