Laserfiche WebLink
3005 Central Avenue TPID # 1574063-01 <br /> Ceres, CA 95307 Pho e 209-537-4881 <br /> Visit us on our website at www.mccoysindustrialtire.com Fax 209-537-7388 <br /> Customer .. ���sr-� l&�c. Loa: Date <br /> Addressr°�<�;„ 1 �,1(� TPI # <br /> City, State, Zi i i� ° h/ �4... �;. Con act <br /> Phone# =? J it PO <br /> No. Q ty Tire Size Tread Design P/F/S <br /> - <br /> 2 �fi <br /> 3 Cdj `l <br /> tJ 4eL <br /> :i v .) <br /> r . <br /> 6 S- <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 1z <br /> Load Amount �, Load Type LiC <br /> l / [ w�iole Tires [ ]Tons ]Pounds [ )Cubic Yards State Califot is <br /> ]Pickup [ ]Delivery Decal # <br /> Customer Namp(Please Print) Cus omer Signature <br /> °i certify that under penal of perjury under the laws of the State <br /> t fRat .. of California that the in rmation provided above is true and <br /> ti •' 4 <br /> correct._ <br /> Driver's Name (Please Print) ri er's Signature <br /> l7 'I certify that under penal of perjury under the laws of the State <br /> Date of California that the information provided above Is true and <br /> o��iUat� correct.In addition,i am aware that falsification of this information <br /> may result in suspension, -evocation,or denial of renewal of the <br /> waste Tire Hauler Reg! tratlon pursuant to Public Resource <br /> Code section 42960 an may result in civil penalties up to <br /> `r $25,000 per day,per viol tion or administrative penalties up to <br /> • $5,000 per violation per(ay as described In Public Resource <br /> Codef section 42962." <br />