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i <br /> :o 1 111 (1 No.- 9066 � <br /> 3005 Centra) Avenue TPID #1574063-01 <br /> Ceres, CA 95307 Phone 209-537-4881 <br /> Visit us on our website at www.mccoysindustrialtire.com Fax 209-537-7388 <br /> Customer _1 ,:- r » <br /> 2 �. Loa Date <br /> Address_,._..... - TPi # <br /> City, State, Zips�� ,<<�-� ( _t-r� Co act <br /> Phone# PO It <br /> No. Qty Tire Size Tread Design P/F/S <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> $ <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> Load Amount Load Type Lic # <br /> Whole Tires [ Tons [ )Pounds Cubic Yards State Callfor la <br /> pickup [ IDeliveiy Decal # <br /> LT <br /> Customer Name(Please Print) GuE tomer Signature <br /> L f a } I� Y "I certify that under penal y of perjury under the laws of the State <br /> ( of Callfornia that the In ormation provided above Is true and <br /> n n Date `� c rrect. <br /> Driver's Name(Please Print) Dr vers Signature <br /> "1 certify tha under penal of perjury under the taws of the State <br /> of Califo nia that the In ormation provided above is true and <br /> Date y� Date correct.19/addition;I am aare that falsification of this information <br /> ��o a may result in suspenslonrevocation,or denial of renewal of the <br /> Waste Tire Hauler Regi tration pursuant to Public Resource <br /> v`ta `y Code section 42960 a d may result in NO penalties up to <br /> $25,000 per day,per viol tion or administrative penalties up to <br /> $5,000 per violation per day as described in Public Resource <br /> Code section 42962." <br />