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'r 01 f?7 <br /> 3005 Central Avenue Ceres, CA 95307 TPID # I574063-01 <br /> Visit us on our website at www.mccoysindustrialtire.com P 209-537-4881 <br /> ��E <br /> Customer { - `'' ' '' Load Date <br /> MAR A. <br /> Address TPID# <br /> H RR`•CK COM-1 <br /> _ <br /> City, State,Zip AGCOU-N r Contact <br /> Phone# PO# q <br /> No. Qty Tire Size P/F/S Tread Design/Labor R&R Disp RSN FI <br /> tis.,3,E", il <br /> 3 _it <br /> Frl, k a u �.•ti <br /> 4 <br /> 5 FAY <br /> 6 <br /> 7 <br /> 8 <br /> -9 <br /> Set up Press Trailer[ ] Service Call[.r`] Unit# - Hours <br /> Load Amount Load Type <br /> Llc # <br /> [`'Whole [ ]Tons [ ]Pounds [ ]Cubic Yards State California <br /> [,]Pick up [ ]Delivery Decal # "f <br /> r <br /> 1 Customer Name(Please Print) Y Customer Signature <br /> "I 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 /> Date . <br /> Drivers Name(Please Print) `Driver's Signature <br /> "I certify that under penalty of perjury under the laws of the State of.Califomia <br /> that the information provided above is true and correct. in addition,I am aware" <br /> Date that falsification of this information may result in suspension,revocation, or <br /> denial of renewal of the Waste Tire Hauler Registration pursuant to Public <br /> Resource Code section 42960 and may result in civil penalties up to$25,000 <br /> Da L' xr per day,per violation or administrative penalties up to$5,000 per violation per <br /> day as described in Public Resource Code section 42962-" <br /> W� <br /> W - y <br /> r; <br />