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• - i <br /> 3005 Central Avenue a <br /> TPI # 1574063-01 r <br /> Ceres, CA 95307 Visit us on our website: <br /> Phone 209-537-4881 Fax 209-537-7p88wMi.mccoysIndustrialtire.com `y <br /> Customer �� t, r�Lw71 i vt� Loa• Date V <br /> Address . . t, .. TPI[)# 17 <br /> City, State, Zifl ) /t' <br /> Con act <br /> Phone# PO# <br /> No. ty Tire Size Tread Desimi P/F/S <br /> a a r s __ 1 <br /> 2 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 'L 7 i <br /> -Uu <br /> Load Load Type Lic# :. <br /> Amount � I-f <br /> ,)Whale Tires [ Tons Pounds Cubic Yards State Californ a <br /> Picku Dtalive <br /> Decal # l <br /> /1 1 <br /> •--���'>� �-"7�'l/ •ti � '� f fir <br /> Driver's Name(Please Print) ' Driver's Signature Date <br /> "I certify that under petmItyof perjury tinder the iatss of the St to ofCalifornia that the infomnatiom provided above is trite and cor�`t.In addition,I am aware that falsification <br /> of this information may result it,suspension,revocation,or 4-vial cfrenewai oftlie Nvuste Tire Hauler Registration pursuant to Pit blic Resourcc Code section 42960 and Way <br /> result in civil Iienalrics tip to 525,000 per day,per violation or administrative peneltics up to S5,000 per viols lion per day as descritd in Public Resource Code section 42962." <br /> Customer Name(Please Print) Customer Signature Date <br /> "I certify that under email of ier'tt under the latus ofthe$tate of California that the infonnatiou gravid d above is true and correct, <br /> McCoy's Industrial Tire has been authorised by CalRecycle to pariticipate In the Waste and Used Tire wanifest EAT electronic reporting program, On ,. <br /> bebalfof the customer listed ori this forut McCoy's Indushial Tirc will electronically transmit to CulRecyle all require)d information from this manifest form. <br /> Confidentiality Claim: Tlic information provided on this form slrall be considered confidential,proprietary,and/or t de secret.In accordance with Title 14, <br /> CCK section 17041 et.Seq,should any member or the public request disclosure of this information,I request that the CtilRecycle contact rine at the address <br /> and tele hone number listed on this form <br /> If this box is checked the following appl es: <br /> 1.Tiles wefe delivered to our own facility. <br /> j <br /> 2. Our facility TPID is the same as'our hauler TPID. <br /> 3. The date and amount of the pickup and delivery are the same. <br /> Received by Delivery Reciept At D _ <br />