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N@W§ him" rn ka <br /> 3005 Central Avenue Ceres, CA 95307 TPID # 1574063-01 <br /> Visit us on our website at www,mccoysindustrialtire.com P 209-537-4881 <br /> Customer P¢ 3 Load Date <br /> Address TPID# <br /> City, State, Zip `lCZ` C� `{'� Contact <br /> Phone# PO# <br /> No. Qty Tire Size P/F/S Tread Design/Labor R&R Disp RSN FI <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> Set up Press Trailer tl\/ Service Call [ ] Unit# Hours <br /> Load mount Load Type Uc # <br /> j1 [ q hole [ ]Tons [ ]Pounds [ ]Cubic Yards State California <br /> [ bPfck up [ ]Delivery Decal # ; <br /> Customer Name(Please Print) CuiNgmer Signature <br /> "I ify hat under alty of jury under the laws of the State of California <br /> that the i provided above is true and correct. <br /> Im )Dat <br /> Driv s Name(Please Print) Driver's Signature <br /> "I certify tha der penalty of perjury under the laws of the State of California <br /> that the info ation provided above is true and correct. In addition, I am aware <br /> Date that falsifi' tion 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`i�C MALI !� 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 /> F <br /> ry <br />