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10 <br /> 3005 Central Avenue , TPID # 1574663-01 <br /> � i <br /> Ceres, CA 95307 Phone ' 209-537=4881 <br /> Visit us on our website at www.mccoysindustrialtire.com Fax 209-537-7388 <br /> f- C.,. Jr <br /> Customer ``�7 � / z Load.Date ZC <br /> Address ' TPID# ' <br /> City, State, Zip �'� .f"�c �: ; , tContact <br /> Phone # PO # �(e) <br /> No. Qty Tire Size Tread Design P/F/S <br /> 2 Y6/ <br /> 4 <br /> 5IRFICPAIEP <br /> 6 9 Y nt <br /> eta <br /> 7 a ) <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> LoadAmount Load Type Lic # <br /> ` <br /> -]Whole Tires Tons ]Pounds Cubic Yards State California <br /> Pick up Delivery Decal # /` L�`%� <br /> Customer Name(Please Print) Customer Signature <br /> "I certify that under penalty of perjury under the laws of the State <br /> of California that the information provided above Is true and i <br /> Date correct. <br /> Driver's Name(Please Print) ' "Orivee-s Signature <br /> ��- "I certify that under penalty of perjury under the laws of the State <br /> of California that the Information provided above Is true and <br /> Date correct.In addition, I am aware that falsification of this Information s <br /> �AO*�c�a ?�A- may result in suspension,revocation,or denial of renewal of the <br /> Waste Fre Hauler Registration pursuant to.Public Resource ' <br /> W <br /> R, Code section 42960 and may result in civil penalties up to <br /> _ $25,000 per day,per violation or administrative penalties up to <br /> . . $5,000 per violation per day as described in Public Resource <br /> Code section 42962." <br /> u , . <br />