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3005 Central Avenue Ceres, CA 95307 TP]b# IS7.4063-01 <br /> Visit us on our website at www.mccoysir Ydustrialtire.com P 209-537-4881 <br /> Custornora C..KJ*:�/ Load Date (� <br /> Address -:QF e" TPID# <br /> City;State,Zip 9�4,fz.. J;:Y Contact <br /> Phone# PO# <br /> No. Qty Tire Size P/F/S Tread Desi .alcor R&R Disp RSN FI <br /> 2 0^ <br /> 3 <br /> .iAq <br /> 6 <br /> '8- <br /> 9 <br /> 9 <br /> Set up Press Trailer[ ] Sarvice Call [ ] Unit# _ Hours <br /> Load Amount Load Type Lic # U - <br /> J hole [ ons ]Pounds Cubic Yards State Califorgia <br /> L ick up JI)eINLeH Decal # C <br /> Wit (-`—` <br /> Customer Narne(Please Print) Customer Signature <br /> "i certify th der penalty of perjury under the laws of the State of Cal[forttla <br /> t at the Information provided above is true and correct- <br /> Date <br /> river's Name(Please Print) ignature <br /> "I certify at under penalty of perjury under the laws of the State of California- <br /> that th " formation provided above Is true and correct.In addltlon,I am aware. <br /> Date that d 10—ti m of this information may result in suspeh9ion, revocation,or <br /> denial of renewal of the Waste Tiro Hauler Regletration pursuant to Public <br /> Resource Code section 42960 and may reautt in civil penalties up to$25,000 <br /> i��a <br /> 4� +�)� per day,per vfclatlon or administrative pena{tles up to$S,OOD,per violation par <br /> '„ day as daserlbed in Public Resource Code section 42962." <br />