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V�/ If/zU14 1f.zz r A A zVZJU6ff, MULUy ti INUUJI(IdI IIIC LgjvuI/VVI <br /> �� . ..... No. 7909 <br /> 3005 Central Avenue TPID # 1574063-01 <br /> Ceres, CA 95307 Phone 209-537-4881 <br /> Visit us on our website at www.mccoysindustrialtire.com Fax 2_09-5377388 <br /> Customer'( a �� MND Load Date 7 2 <br /> Address 22 2 t TPID# <br /> Ci , State, zi r3vi-a LA-- Contact <br /> Phone # PO # Sr &PY <br /> No. Qty Tire Size Tread Design P/F/S Notes Inspected <br /> 2 A- ��- SJ 13 l <br /> 4 Lt 4622 * Z <br /> 5 � <br /> 6 <br /> 7 <br /> 8 <br /> 9 t-( <br /> Load Type Load Amount [ Pick up [ ] Delivery <br /> [V4ole Tire [ ]Tons Lic# '��7 bo -L-7 State CA <br /> ,flPounds Cubic Yards Decal # l f <br /> river's Name (Please Print) Drivers Signature Date <br /> "I catifir th under perWty of perjury uoder the laws ofa State of Califomiu that the information provided above is true sad correct.In addition,I am aware that falsification <br /> of this information may result in rrspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resource Cade scaion 42960 and may <br /> result in civil penalties up to$25,000 per day.per violation or a niatrative PCnalcie.9 up to$5,000 par violation per da•as described in Pubic Resource Code section 42962." <br /> Customer Nam Please Print) Customer Signature Date <br /> "I cern that tutder enal 'of a under the la f e State of California that the infortnation proiided above is true and correct_ <br /> McCoy's Industrial Tire has been authorized by CalRecycle w pariricipate in the Vlrastc and Uscd Tire manifest EDT electronic reporting pro&jam. On <br /> behalf of the cuctnmer listed on this form McCoy's Industrial Tire will electronically transmit to CalRecyle all required information from this manifest form. <br /> Data Two <br /> Confidentiality Claim: The inforiyation provided on this form shall be considered confidm ial, <br /> M proprietary,andlor trade secret.In accordance with Tide ld,CCR section 17041 et.$eq,should <br /> r o any member of the public request disclosure of this infomiation,I ragwa that the CalRecycle <br /> contact me at the address and telephone number listed on this form <br />