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1-209-242-3051 14:07:52 07-11-2013 11 /33 <br /> YYILLJV/Y VI IME: L011i l/Vl,. LEET SERVICE RECORD 601113 <br /> U.S. IRE SALES J „111 <br /> TPID 1000837 16 5 5 0 8 <br /> 101 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #14 US Tire Sales <br /> !21 N.Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 NationalAve, 6530 Franklin Blvd. <br /> ;tockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> !09-465-0281 209-465-3162 209.466.2581 209-571-5611 510-887-1282 916-395.2245 <br /> :USTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICEc <br /> OCAT OF SE(R�ICEE /!� STATE ZIP CODE <br /> r <br /> CUSTOMER TPID DECAL# <br /> I certify that under penalty of erJury under the laws QF the State of Califomla that the Information provided above Is true and cortecL In addition,I am aware that falsification of <br /> this information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result In civil pe es up to$25,000 per day,per violation of administrative penalties up to$5,000 per violation per day as described In Public Resources Code section 42962. <br /> )RIVER NAME DRIVER <br /> IVER SIGNATURE DATE <br /> CUSTOMER •' • <br /> RAKE TRUCK/TRAILER# LICENSE STATE OQOMETERIHUB <br /> SPECIAL INSTRUCTIONS' ON OFF <br /> qT X WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESMPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> - AIR SERVICE LOOSE MOUNT(S) REBUILD(S) <br /> _ <br /> :ti►y;;, VALVE STEM REBUILDS <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> QTYIZ�. MFd DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: C/t2�51 <br /> M <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM: <br /> V-5 FINISH TIME: +? A <br /> LOAD AMC T ^ HAULER EXEMPTION IFAPPLICABLE <br /> C/ ❑GOVERNMENT L) LEA EXEMPT OTHER ' <br /> •—— <br /> ❑AGRICULTURE _- <br /> ❑COMMON CARRIER/BACK HAUL <br /> .Z31PICK UP Py' LOAD TYPE <br /> ❑ IMPORT FROM <br /> [3 DELIVERY L24HOLE TIRE COUNT ❑WEIGHT IN POUN15S <br /> ❑ EXPORTTO d? 0 ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> c pato I certify that nd r penalty of paqury under the laws of the State of California that the Information provided above Is true and correct In addition,I <br /> Sod �r a arm t t aificatlen of this Information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> $ ,00 r tlo a, n perday as described In Public Resources Code sectlon42962. <br /> w m <br /> • <br /> COSTO R PR N NAM CUSTOMER SIGNATURE DATE <br /> FSR No. 1 6 g;5 n R PLEASE CIRCLE STORE LOCATION AT TOP <br /> Received Tule Jul, 11, 20' ) 2 : 02PM No. 0719 <br />