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'1-209-242-3051 14:10:15 07-11-2013 17/33 <br /> rr'A—Jvw 4y I IKt (:U-1 ING. FLEET SERVICE RECORD <br /> U.S. TIRE SALES <br /> lSf TPID 1000837. 16845-6. <br /> #01 Wilson Way 77re Wilson WayTire Recap 1 US <br /> p #!12 Cannell Tire #21 U5Tira Sales #23 US Tire Sales #24 US Tlre' a(� <br /> 221 N. Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Fran;l a <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 - Modesto,CA 95354 Ha <br /> 209.465-0281 209-465-3262 209-466-2581 209-571-5611 yward,CA 94545 Sacramento 3 <br /> 510 687-1292 <br /> CUSTOMER 916.395-2245 <br /> P.O.# DATE <br /> v VI/y <br /> PHONE VEHICL # <br /> LICENSE <br /> LO;AI DAL nc e <br /> -�----_..r,ERV I C E <br /> STATE "ZTFCODE <br /> CUSTOMER T D / I� DECAL# <br /> I certify that under penalty of perjury.Under the laws of the State -1of California that the Information provided above Is true and correc � <br /> this Information may.rnsult In suspension,revocation,or denial of renewal of the Wa In addition,I am aware that falsification of <br /> ste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result In civil penalties up to$25,0011 per day,per violation of adminl5tralive penalties up to$5,000 per violation per day as described In Public Resources Code sactl[ 42982. <br /> DRIVER NAME DRIVER SIGNATURE <br /> X .PATE , <br /> a <br /> MAKE TRUCKlTRAILER# LICENSE STATE <br /> HUB <br /> / r-;P Sf7 <br /> Ik"f• '� } :.:z,.."�� Rv —4�(f'lr�Ey.?f�"'°�NA,T„FALk tf�"'. �b4'?�ll ��.`:” Yc j �n s,�r •s heti-,.- �; ,t . <br /> • U/ � .. :•w Lam. �^� q 1 :' .+� L..�: wrrC ,�,"°�.._ �. ri� <br /> .Q.^f (J915Te:4F.r Vel+0•J� '^"'.�l-f, F;.s:.'1 ' T 'Y .3'YV '+A�! fi:�"t' .5r- A+ _ -•r <br /> .. a .. ..1.:.:r. <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) VALVE STEM REBUILD(S) <br /> Fl AT REPAIRS) 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 /> p� �, ry �� • <br /> ' yptr FINISH MILES: <br /> Rr <br /> �� START MILES: <br /> TOTAL MILES: <br /> START TIME: <br /> ON SITE TIME: AM pM <br /> OUT TIME: AM PM <br /> FINISH TIME AM PM <br /> LOAD AMOUN i .jy".r `, 7:K rr+bc 3 .+ ;x,`' tE '.. h +•, ° mrd u <br /> ❑ GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> —— AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ICK UP '713a a �e m,� `.i M ' ar <br /> ❑ IMPORT FROM <br /> ❑ DELIVERY Q WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORTTO j ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> �c Dote, I certify that under penal f perjury undor the laws of the State of California that the Information provided above Is true and correct.In addition,I <br /> = o am aware that fol adon of biy,inrgrmatlon may result In Civil penalties up $25,000 per day, par vlolat(on or administrative penalties up to <br /> $5,000pervlofatlo pe day as As'rlbe'dT6FlublrcResourcesCodesection42262. <br /> Y .. <br /> dUiTOMER'PRI14T NA '^I :p CUSTOMER SIGNATURE DATE <br /> F$3-i--,No. 16 8 4 9 6 tl1 .� <br /> Rc e l v e d Time Jul, 1 1. 2 413 2 0 2 P M'�N o, 0 71 y �CLE STORE LOCATION AT TOP <br />