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FROM (FR I ) JaN 21 2011 ��13 ; 04/No. 6661196751 P 3 <br /> q :>o� <br /> Wr & TIRE CO,, INC, EET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1010837. 139631 <br /> 001 fflkwn Way Tire N71son Way nr a Recap X02 Conne6 The 1121 US Tiro Seks 023 US Me St hs M US Tku Saha <br /> 221 N.Wilson VAy 1334 Akrw$1. 2211 N.woson Way 2600 Yoaernlfe Blvd. 1910 Nadanal Ave. 6380 f,YeWin Blvd. <br /> S1oe/Aon,CA 06206 Sftwlrfaa,CA 06205 Shwitfon,CA 91203 Modesto,Q4 90354 Hayward,CA 14545 Sacrerlrartf%CA 93829 <br /> 20"0"281 200-45-3262 209.486-2561 610.607-1.268 916496.2246 <br /> CUSTOMER! I P.O.aY �D �_ DATE <br /> Ill <br /> PHONE VEHICLE# <br /> LICENSE# <br /> L]ib <br /> LOCATION SAERVIgq 7J•)r.CODE <br /> 12 did, <br /> CUSTOMER TPIDDECAL>'� <br /> I afft hast Under PotWb of perjury under the lawrof the Rate of Califomis that the Information provided above Is true end correct In addltte n,I am aware titaM tMN1lCiebere of <br /> this kdwmW*n may heult In cusp onion,revocation,or dsrdal of mnaml o1 the Wasie Tim Mwler Ibastrpalan pursuant to Pupils Resourm Cods section 42M and stay <br /> rnsull In andl pwokles up to$U,000 per day;per vloledon of edminletrative penalUa up to$9,000 per vlolsdon par day as described In Public Raaourus Code se ct10f1 41062, <br /> DRIVER WE DRIVER SIGN -Li SATE _ <br /> X 1 <br /> MAKE TRUOVTF AILER N LICENSE STATE ODOME rtA/HUB <br /> - <br /> to I z.:; , s_: <br /> )'3D t- I�TIGNGIP =VEHIICLE <br /> 7 SERVICE CALL MOUNT/DISMOUNT(S) BRASS-VALVE STEMS) <br /> FLEET INSPECTION MOUNT/DISMOUNTS) ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE 3 fEM REBUILD($) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(5) ALLIGAT DR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL V+iLVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O R(NG(3) <br /> t e5. '�r. _;. <br /> FINISF MILES: <br /> t START MILES: <br /> TOTAI MILES: <br /> STAF T TIME _ AM vM <br /> ON SITE 11ME: AM PM <br /> OIL TTIME�_ _ ASA PM <br /> FINISH TIMF: `R) AM PM , <br /> LOAD AMOUNT I It' t ii!'.' :c " '3•' �I ;HAL1LEr3_ I <br /> Q GOVERNMENT Q LEA EXEMPT ❑OTiER <br /> AGRICULTURE LJ COMMON CARRIERIBACK HAUL <br /> PICK UP ' I <br /> ❑ IMPORT FROM 5I_� Y ) I Q .. WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> DELIVERY <br /> CI FxPORTTO ry I' ❑VOLUME CUBIC YARDS Q WEIGHT IN TONS <br /> 1 certify that under penalty of perjury under the lays of 161 State of California that the Information Provided above Is true Bred oorroot.M addldon,I <br /> Dofor� am cream that falaMeation of this Inforowdon may result In civil se up$26,000 P day,per Matlon or admin s penalties up to <br /> S3,%0 pet violation p_00.0er as described In Public Resources Code a <br /> CUSTOMER NT NAME CUSTOMER 41 ATUR DATE <br /> FSR Noe 139631 <br />