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3005 Central Avenue Ceres, CA 95307 TPID # 1574063-01 <br /> Visit us on our website at www.mccoysindustrialtire.com P 209-537-488/1 l <br /> Customer ?A Load Date <br /> Address �j TPID# /CC <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 /> 7r i <br /> 2 "7i 7�/ 6-' �' �✓ <br /> i <br /> 3 <br /> 4 <br /> 5 J,, <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> Set up Press Trailer[ Service Call ( Unit# Hours �(:r <br /> Load Amount Load Type Lic # <br /> [hole [ ] ns [ ]Pounds [ ]Cubic Yards State California <br /> ick up ]Delivery Decal 401 <br /> t � _ <br /> Customer Name(Please Print) `f._ Cu to er Si a ure <br /> "I certify that rider penal roKperjury under the laws of the f California <br /> that 0rmation provided above is true and correct. <br /> Dat <br /> Driver's Name (Please Print) Drivers Signature <br /> "I certifyth under penalty of perjury under the laws of the State of California <br /> that the i mation provided above is true and correct. In addition, I am aware <br /> Date that fall ication of this information may result in suspension,revocation,or <br /> denial of renewal of the Waste Tire Hauler Registration pursuant to Public <br /> Resource Code section 42960 and may result in civil penalties up to$25,000 <br /> 1)at�T}._ 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 /> :ro <br /> La <br />