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r.W .. _ .. .... <br /> ' No. 8913 <br /> 3005 Central Avenue TPID # 1574063-01 <br /> Ceres, CA 95307 Visit us on our website: <br /> Phone 209-537-4881 Fax 209-537-7388 www.mccoysindustrialtire.com <br /> Customer ^-� - (ZL 02:, Load Date <br /> Address �y,�o o��yU�( �c� TPID# <br /> City, State, Zip Contact <br /> Phone # PO # <br /> No. Qty Tire Size Tread Design P/F/S <br /> 116 <br /> 2 <br /> 3 r <br /> 4 � - <br /> 5 <br /> 6 <br /> 7 <br /> 8 (of <br /> Load Load Type Lic # $ 0 <br /> Amount <br /> hole Tires Tons. Pounds [ Cubic Yards State California <br /> ick u ]Delivery Decal # % ' 'zc 3 <br /> Driver's Name (Please Print) Driver's ignature Date <br /> "I certify that under penalty of perjuryunder the laws of the State of Cafornia that the information provided above is true and correct.In addition,I am aware that falsification <br /> of thus information may result iii suspension,revocation,or denial of re ewal of Ute Waste Tire Hauler Registration pursuant to Public Resource Code section 42960 and may <br /> result in civil penalties up to$25,000 per day,per violation or administrative penalties up to 55,000 per«olation per day as described in Puhlic Resource Code section 42962." <br /> Customer Name(Please Print) Customer 119nature Date <br /> "I certify that tinder penalty ofperjury wider the laws of the State of California that the information provided above is true and correct. <br /> McCoy's Industrial Tiri�'has been authorized by CalRecycle to pariticipate in the Waste and Used Tire manifest EDT electronic reporting program. On <br /> behalf of the customer listed on this form McCoy's Industrial Tire will electronically transmit to C.alRecyle all required information fi-om this manifest form. <br /> Confidentiality Claim: The information provided on this form shall be considered confidential,proprietary,and/or trade secret.In accordance with Title 14, <br /> CCR section 17041 et.Seq,should any member of the public request disclosure of this information.I request that the CalRecycle contact me at the address <br /> and telephone number listed on this form <br /> [ If this box is checked the following applies: <br /> `tov-�c Dat;r T^d'i <br /> F 1. Tires were delivered to our own facility. <br /> 2. Our facility TPID is the same as our hauler TPID. <br /> 3. The date and amount of the pickup and delivery are the same. <br /> Received by Delivery Reciept#D .__ <br /> l <br /> I <br />