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3005 Central Avenue Ceres, CA 95307 TPID # 1574063-01 <br /> Visit us on our website at www.mccoysindustrialtire.com P 209-537-4881 ' <br /> CustomerA fJkZ <br /> 4,/ Load Date <br /> Address TPID# <br /> City, State, ZipContact <br /> Phone# PO # <br /> No. Qty Tire Size P/F/S Tread Design/Labor R&R Disp RSN FI <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> Set up Press Trailer[ ] Service Call [ ] Unit# Hours <br /> Load AmountLoad Type Lic # <br /> [ Whole ]To 2s [ Pounds [ ]Cubic Yards State California <br /> ^ [ ck up [ ]Delivery Decal # r> <br /> • v ' 2ammj <br /> Customer N me( lease Print) Customer Signature <br /> r I <br /> OA <br /> �`7 n ` I certify that under pen ty of perjury under the laws of the State of California <br /> (�K Iv that the info mation provided above is true and correct. <br /> \Date t� �d <br /> Drivers 'N a (Please Print) Driver's Signature <br /> "I ify that under penalty of perjury under the laws of the State of California <br /> tha the information provided above is true and correct. In addition, I am aware <br /> Date that falsification of this information may result in suspension, revocation,or <br /> denial of renewal of the Waste Tire Hauler Registration pursuant to Public <br /> Resource Code section 42960 and may result in civil penalties up to$25,000 <br /> o�,,o DatJ per day,per violation or administrative penalties up to$5,000 per violation per <br /> day as described in Public Resource Code section 42962." <br /> 41 <br /> 1d 2 <br />