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FROM (FRI) JRN 21 2n{ 1 � E RECORD <br /> 13 ;04/No. 6661196751 P 2 <br /> WS� TIRE CO. INC. EET SERVI <br /> C . <br /> U.S. TIRE SALES TPID 1000837. 139934 <br /> 1101 wu on MY nre W IS00 Noy T1re Recap sc2 Go"nuff TLa M21 Us T"sales 820 us The Sates ' at21 US 71n Saba <br /> 221 N.W/lson Way 1835 fite,lret8t. 2211 N.INrl""Way 2000 Vosarnlro Blvd 1016 Nedw)N,we. 8600 Prenkgn Bbd. <br /> Stockton,CA 05Md stockl!W4 CA 832116 8009"00,CA 06205 Modesto,CA 0W61 Hayward.CA I4U5 Sacramento,CA JSM <br /> 20D-186-0281 20"6&3262 209.166.2581 20D•571.3811 510-887-1288 Y18.JD5.22{6 <br /> CUSTOMER l 3 P.O.0 DATE <br /> PHONE VEHICLE$ <br /> LICEN9E 6 <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CIL! <br /> STQMER TPID r- I DECAL At rl— 11 7�- <br /> 10'-- <br /> 1 CwWy thin under penalty of perjury under the laws of the Stab of Callfornia plat the Irrformatlon provided above In true and cornrct In additie%I am aware that tatelficatim of <br /> thla Ihfon radon may result In suspension,rwvooatlon,or denial of renewal of 1M Rate Tire Hauler Registration prusuard to Public Ilaooureas Coda section 42911 and mq <br /> moult In civil pgnshMa up to 126.000 per day,par vtaation of admlrrb0edhe pa atwa up w S5,000 par vlolation per day sa described In Public Resources Cods seetaon 12907. <br /> DRIVER NAME OR TGNATURE. _, )ATE <br /> x - _ �.) <br /> TRUCK/TRNI-ER aY LICENSESTATE yc ODOME7ERMUE <br /> 77 <br /> -------------- <br /> E �►iii, '.,� �:�� pvvrw :r ' <br /> .aiERVICE CAL r() 6 MOUNT/DISMOUNT(S)ON VEHICLE' Pr• BRASS bALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(6)LOOSE ALUMIN(IM STEM($) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE S-fFM REBUILDS) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAPS) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEELS) O RING(:) <br /> ,- a .,:' `,r: „r: - FINISH MILES <br /> LL <br /> START MILES: <br /> TOTAL MILESIJ : <br /> eP i%+ �-. STAF T TIME: `S,- ' C) AM(My <br /> ON SITE TIME; AM PM <br /> OUTTIME: AM PM <br /> FINIS 1 TIME: AM�� <br /> LOAD AMOUNT MAtULLFA(��i9�?•..!_ 'I 'r.}R {.. i. <br /> IZ • D GOVERNMENT Q LFA EXEMPT ❑OTHER <br /> AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ' ,i' s t. <br /> PIC IMPORT FROM � CJI IlF�� Lf _ „ is� a <br /> Q DELIVERY — LJ-WHLJ-WHOLE�wOLE TIRE COUNT (J WEIGHT IN POUNDS <br /> L-�-�PORT TO ❑VOLUME GUSIC YARDS Q WEIGHT IN TONS <br /> I cenlfy prat under penally of perjury under the taws of the State of CaNtomia Oat the Information provided above Is true and correct In addition,i <br /> Doty f' am aware that Mtellloatlon of this Intormadon may result In civil penalties up.126;000 par day,per vinlet on or adminlsQetlw w ahWs up to <br /> 16,000 par vioiatlon day as described In Public Resources Code aeatlon,. <br /> CUSTOMER PRINT NAME Cus R SIGMA. <br /> FSR Nim. ng9.,in <br />