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i <br /> I <br /> NOW$ _...., �. 1.0.2' 3 I <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 G Load Date <br /> Address <br /> City, State,Zip` e7�J �, Contact <br /> Phone# PO# <br /> No. Qty Tire Size P/k'/S Tread Desi. /Labor R&R Disp .:::,. RSN F1 <br /> 2 1 <br /> 3 <br /> . 4 <br /> 5 IOD 6 <br /> 6 <br /> 8 d- <br /> 5 <br /> Set up Press Trailer[ ] Service Call ] unit*' Hours <br /> Load A aunt Load Type Lic t <br /> Whale[ Tons ]Pounds cubic Yards State California 00 <br /> [ ]pick u [ ]Delive Decal ## t7 <br /> c(OAAA : <br /> Customer Name( ase Print) Customer Signare <br /> "I certry certify that•undar penalty of perjuwider the aws of the state of Californla <br /> _ that the Infortnatio -'provided above is true and correct. <br /> Date <br /> Driver's Name (Please Print) Driver's Signure <br /> 'I certify t t under penalty of perjury under the laws of the State of California <br /> —_ that tho i ormatlon provided above is true and correct.In addition, I am'aware <br /> Late that fa ifieatlon of this information may result in suspension,revocation,or <br /> denial of renewol,of the Waste Tire Hauler Registration pursuant to Pubfic <br /> ��Darr Resource Code section 42960 and may result In civil penalties up to$25,004 <br /> 4.p ra per day,per violation or administrative penalties up,to$5,000 per violation.por <br /> �A ��, day as described In Public Resource Code section 42962_" <br /> alt <br /> FIL .:fav � y <br />