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No. 8 55 7 <br /> 3005 Central Avenue TPID # 1574063-01 <br /> Ceres, CA 95307 Visit is on our website: <br /> Phone 209-537-4881 Fax 209-537-7388 www.mccoysindustrialtire.com <br /> Customer D Q a n Load Date — 7-- <br /> Address <br /> Address -4" ock4olj AUL TPID 1; "-7' d2v 1 <br /> City, State, Zip' ` R`,oah 9-53 d( Contact <br /> Phone # PO <br /> No. Qty Tire Size Tread Design P/F/S <br /> a'/ A���r <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> Load Load Type Lic # —60 � <br /> Amount <br /> Whole Tires ]Tons Pounds Cubic Yards State California <br /> [J]Pickup [ Delive Decal # (, += <br /> - I <br /> Driver' Name(Please Print) Driver's Signature Date <br /> -'I certify that under penalty ofplry under the laws of the State of California that the information provided above is true and correct.in addition,I am aware that falsification <br /> of this information may result in suspension,revocation,or denial of renewal of the waste Tire Hauler Registration pursuant to Public Resource Code section 42960 and may <br /> result in civil penalties up to$25,000 per day,per violation or administrative penalties up to 55,000 per violation per day as described in Public Resource Code section 42962." <br /> • ,��sti�t� .- 7- /S <br /> Customer Name(Please Print) Customer Signature Date <br /> "I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct. <br /> McCoy's Industrial Tire has been authorized by CalRecycle to pariticipate in the Waste and Used Tire manifest EDT electronic reporting program On <br /> behalf of the customer listed on this form McCoy's Industrial Tire will electronically transmit to CalRecyle all required information from this manifest forni. <br /> Confidentiality Claim: The information provided on this form shall be considered confidential,proprietary,and/or trade secret.In accordance with Title 14, <br /> CCR section 17041 et.Seq,should any member of the public req est disclosure of this information,I request that the CalRecycle contact me at the address <br /> and to hone number listed on this form <br /> op,C n'I t., <br /> [ If this box is checked the following applies: <br /> �� 1. Tires were delivered to our own facility. <br /> trrr 2. Our facility TPID is the same as our ha 'er TPID. <br /> 3. The date and am o t of the pickup and elivery are the same. <br /> Received by Delivery Redept#D <br /> J <br />