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3005 Central. Avc rhue `'PID #1574063--01 <br /> Ceres, CA 95307 Phone 209-5374881 <br /> Visit us on our website at www.mccoysindustria[tire.com Fax 209-537-7388 <br /> Custom er0c,/� I )~ Load Date <br /> Address .0 3 �', Pr TP1D# <br /> City, Mate, Zip 10 r-l� v 1/ G. �} contact <br /> Phone# .. ��L D K,1 ) .2f51'�V 7 5` 1 PO # <br /> No. Qty Tire Size Tread Pesi PMIS <br /> 2 <br /> 3 <br /> 4d <br /> 6 <br /> 7 <br /> 8 <br /> 10 <br /> 12 <br /> Load Amount Load Type Lic # . _7, -3 0 <br /> 1 [X]Whole Tres [ ]Torts Pounds [ ]Cubic Yards State California <br /> IxEckup [ ]Delivery decal <br /> Customer Name(Pieas6Print) Custom r Signature(' <br /> jb �, "I certify that under penalty of perjury under the laws of the State <br /> of California that tEe information provided abo1. <br /> ve ove is trwe.and <br /> _ <br /> Driver's Name(Please Ptint)' Driver's Signature <br /> "I certify that under penalty of perjury under the laws of°the State <br /> of California that-tile information provided above'is true and <br /> ' �,`j� a1 Date correct. In addition, I am aware that falsification of this"information <br /> a'� may result-in suspenslon, revocation,or denti_aI of renewal.of the <br /> Waste Tire Mauler Registration pursuant to Phi llo Resource <br /> *? Code section 42960 and may result in civil penaltiaS up to <br /> $25,b00 per-day, per viol9tion or administrative penalties up to"'!E` <br /> $5,OOd per violation per day as described in Public Resource <br /> Code sec ion 42962." <br />