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05/12/2014 10:55 FAX 2095377388 McCoy's Industrial Tire E2002/004 <br /> 1 <br /> No. 7994 <br /> I 3065 Central Me e TPID # 1574D63-01 <br /> Ceres, CA 95307 ' Phone 209-537-4881 <br /> Visit us on our website at www.mccoyslndustrlaltire.com Fax 209-S47-73 8 <br /> i Customer 12 Load Date 7� v 7 <br /> Address y l7l a� r\l�r <br /> > TPID# <br /> City, State Zip Contact <br /> Phone# IPO # <br /> No. Qty Tile Size Tread Desi P/F/S Notes Inspected <br /> 1 2 7CO h !v JL <br /> 2' Z `{ ,,. —7 <br /> LC7 O Y � L_. � / <br /> 3 L/ <br /> d 50. <br /> 5 <br /> 6 <br /> 7 <br /> 8 7j- <br /> it <br /> Load Type Load Amount j Pick up [ ] Delivery <br /> [ }'Nhole Tire [ ]Tons �� Lic# / 7A J7. 7 State CA <br /> Pounds Cubic Yards rt Decal 2 <br /> DrIver's Name(Please Print) Driver's Signature pate <br /> '1 certify that under penalty cftomoor, <br /> nndor the lana of the 5r=of Callfornla that the 1afacmaiioa providedabave in truc znd earraer,la addition,I am awun ttiat fasification <br /> of tbic information may rosy� ension,revocation,or denial of re awal of the Waste Tiro Rmu I 'VrA ion pursuant to Public Resource Code section 42960 and may <br /> result in ivil p Alli up t er da,per%iolafian or ed=vvini3t rM oetuhies up to st,DD r elation per day as d=nbed in Public Pvacurqo <br /> (Coda soction 42962." <br /> Customer N rneplease Print) Customer Sign 11're Date <br /> "I Certify dhit under penalty vfpenuztindcr the laws of the State of California that the informationpTmided above is true and coacot <br /> McCoys industrial Tire ba&been atiihorit 4 by CalRccycle To pariticipate in the 1 ozze and.Used Tiro manifest EDT electronic reporting program. Da <br /> behalf of the customer li.ated nn this form MCCay's industrial Tiro~will electronically transtnit to CalRecyle all required lnfotraaiion from this manifest form. <br /> ConndcotiaEty Claim: The infurmarion provided on this form sb4ll be cansidered confidential, <br /> proKr-ietary,&nd/or trade secret In accordant-wi+1t Title 14,CCR section 17441 et,Seq,should <br /> any member of the public request disclosure of this information,I request that rbe CalR.ce;vlc <br /> contact me at the address and telephone number listed on this form <br />