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M <br /> 3005 Central Avenue Ceres, CA 95307 TPID ## 1574063-01 <br /> Visit us on our website at www.mccoysindustrialtire.com P 209537-4881 <br /> Customer ,. Load Date' We <br /> Addressr TPID# •6S' n_cam` <br /> City,State,Zip �g[ � Contact <br /> �— <br /> Phone# PO# 7 .2-� <br /> No. `Qty Tire Size P/F/S Tread Desi t/Labor R&R Disp RSN FI <br /> -3 <br /> 4 <br /> 5 <br /> 7 <br /> 8 <br /> 9 <br /> Setup Press Trailer[' ] Service Cra11 [(,1.! Unit#..._ Hours <br /> Load Amount Load Type Lie # <br /> ole To [ Pounds Cubic Yards Stats Ca(i rnia <br /> [ P u ]Delivery Decal # <br /> ustomer.Name(Please Print) Customer Signature <br /> "1 certify that under penalty of perjury under the laws of the State of California <br /> that the information provided above is true and-correct. <br /> Driver's Name(Please Print) river's Signature, <br /> "I certify that under try,of perjury under the laws of the State of Califomia <br /> that the information vidQd above is-ftue:and correct.In addition,I am aware <br /> Pate that falsification his Information rnay:tesuit in suspension, revocation,or <br /> 'denial of renewal of the.Waste Tire Hauler Registration pursuant to Public <br /> at�a� Resource Code section 42960 and may result in civil penalties up to$25,000 <br /> y,per violation or administrative penalties up to$5,000 per violation per <br /> i ' day as described in Public Resource Code section 42982." <br />