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(TUE)MAY 13 2008 1 " 10/ST. 9 :58/No- 6661196949 P <br /> f s W&4kva TIRE CO., INC. , � :ET SERVICE R <br /> ;. TIRE SALES I` Bio X00083 11357 4 <br /> 001 Myo M'WRY TIM WA—way Tiv hacaP 402 Commat Twe IOA wMadn War Tiro 121 u9 Tlrt Salve It=us Tiw Saios r24 us ri—Fwles <br /> 111 N.wKswr way f ma mirriet St. m 1 N.wltron way 1133 W.Efevonth St_ 2a00 Yoatvrrltt ANvrl, 191S Notional Ara. d0W Frw*fin Blvd. <br /> 5to Atwr,G.962M 99o4klemn Ca."2W Stooitoq ca.9d2to '1'tilroy,G,trrw$ Modesto,CA.W3" Hayward,Ca.84144 Saurown1%CA.95M <br /> 209-46"281 200.0654"2 109-d8&2Mf 299483S.dOd7 20"71d1111 510-807.12" V1Y-Ft s-22i7 <br /> CUSTOMER P.O. # DA <br /> PHONE VEH4CLE <br /> LICENSE# <br /> ��s D <br /> LOCATION OF SERVICE ? ST Cy IP O <br /> V t <br /> CUSTOMER TPID I I I I 4 I I I—� 'I ' DECAL M <br /> — CJI <br /> i cenify that under penatty of pbrjury under the laws o1 tits State of Caltfornla that the In a n pr Idedve I tree an .In addition,I am awary that taiiHitation of <br /> tri is inionnatlon may reeu I suspension,revocation,or denial of renewal of the Tire ult tgi on rs o Publ ourttt Cott SeClion 429%and may <br /> result in civfE penaitltt a to 5,000 per day,per violation or adminittnitive fes up S, per v Natio per as tle ed In Public Resources Code sectlon 42962, <br /> DRIVER NAME DRIVER GNA RE DATE <br /> 7 <br /> MAKF TRUCKITRAiLER If LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> F7-L <br /> U)otlam <br /> Nr7 <br /> OTY, DESCAPTMUF WORK COMPLETED DESCRIPTION OF WORK COMPLETED OTY DESCRIPTION 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 MOUNTS) VALVE STEM REBUILD(g) <br /> FLAT REPAIR(S) LOOSE DISMOUNTS; ALLIGATOR CAP(% <br /> REPAIR MATERIAL($) TIRES)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(15) RECONDITIONED WHEEL($) 0 RINp(S) <br /> Ory. SIZE MFG OEs mPT70N F1NI$H MILES' j <br /> y 7 START MILES' - <br /> TOTAL MILES: <br /> ;TART TIME; <br /> qN SITE TIME.. AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM i4> <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT 0 LEA EXEMPT THER <br /> [] AGRICULTURE ❑ COMMON CARRIEFUBACK HAUL <br /> IP <br /> ICK UP I OAD TYPE <br /> El IMPORT FROM OLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> DELIVERY <br /> E) EXPORT TO ❑ UME CUBIC YARDS 0 WEIGHT IN TONS <br /> I certify that udder penalty of perjury under the Iowa of the State of C or ie that the Inform 'provided abort is true and correct,in addition,I <br /> Ota D0 trr} em aware that falstflcatlon of this Information may result In clod lit up to$26.000 pa ay,per violation or administrative altlea up to <br /> a' r 86,000 per violation per clay as aeecrtbed in Public Aeaourtes CoO n 42W <br /> , � b <br /> CUSTOMER PRINT NAME CUSTOMER SI A7URE DATE <br /> FSR No. 113574 <br />