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Apr, 24. 2008 2:43PV C LL TIRE/GOLDEN STATE TRUCK No, 6481 P. 4 <br /> _ VIIIL .ON Y 1 IRJt 4U., 1NL:. FLE�rt Sh�xv��:ac++ � <br /> 7"1F>tE SALES TPID 000837. 113338 <br /> #01 WNaen Way rh* 4,f1 gy.Tl+.w,R -ol. vd jj firfb dPs"*OfIV wayYlro NTt US Tiro Sales k23 U5 7Fro SOra9 #24 US Tire Sa16a <br /> 22f N.WFleon Way EBBS Afprkht 8£ 2$if tf.Wffinn Wqy.. 1133 W.Eleventh EL "M Yeaemfr4 Blvd. i9fb!National Ave, 653Q EFetlklln BIVd. <br /> Stopkfan,Ca:98208 SMaktan,Op.982;09. Stodkfery 00,99201; Traoy,Ca.95976 Aiadadte,CA,4E384 NaywRr4 Ca.94544 Sacmmanfa,CA.49923 <br /> 2M46"20f 2084653282 p0g48B S6ai 209�89b4007. 40907E 551! 9f0887.7292 926 46 <br /> CUSTOMER P.O.# DATE <br /> •PHONE VEFfL�I f;# <br /> •' LICENSE#_ <br /> LOCATION OF SERVICS STATE IP DE <br /> CA- <br /> CUSTOMER TPID rJ �_�F �j l .L� QECAL# FgT71— -....._ ... ..1�....I <br /> I certify that under penalty of porlury under the(aW9 of the,S(6to of Californlo that the ileo do viae is end rect.In addition,I am aware that falsification at <br /> this Informatlon may,result In susponaloh;rovccailon;or denial of fenewsl of the Wa r Ro on p usn Public Resources Cade section 42960 and may <br /> redid!In civil penaltWs;U�' 3'tS�600 ►keV)psir,;Llblatlbn,ar adminlstretive a a, 5 0 ps I.110. er ee d9s r11}ed 111 Putrlle R6sources Code section 42962. <br /> DRIVER"NAME ( f DR IV SIG DATE <br /> MAKE a1 FIUCit'lTRAIL�R fi>r'.., i v. LICENSE, . <br /> STATE ODOMETERMUB <br /> ThAkt <br /> 77 <br /> a <br /> A <br /> �'4J.r�'.�,,"P Er' •{C. ..� ��� t.' r�' r N )�i ,�I�,,.��ny !-.y'...•`���GY Fl+��;f,K,.�,' <br /> SERVICE CALL MOUNT i DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I DISMOUNT($)LOOSE ALUMINUM STEM(S) <br /> AIR SERVIC;, Aii'r 1.u` a' <br /> 4QOSE MOUNT(S). VALVE STEM RESUILO(S) <br /> FLAT REPNR(S)1 r't' 'r. `^ LOOSE DISMOUNTS) ALLIGATOR CAP(S) <br /> REPAIR MATER(gl( <br /> )„ TIRE(5)BALANCED METAL VALVE CAP(S) <br /> O RINO(S <br /> WHEEL SW17�FI S 1 �•'+ !' ;`�,.•� :,; �,,REGONDITIONED WHEEh(S) ) <br /> �7 FINISH MILES: <br /> `i START MILES: <br /> p 1t` j�`•' —r P. TOTAL MILES: <br /> START TIME: <br /> r''• ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FI'NISN TIME: /r AM It <br /> LOAD AMOUNT <br /> ❑ GOVERNMENT ❑LEA EXEMPT OTHER <br /> —��-- �-- ❑ AGRICULTURE CI COMMON CARRIER/BACK HAUL <br /> ICK UP "`.`....., .!aEd "`' , ` <br /> C7 IMPORT FR/JI+R.. I~ p WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ELIVERY - <br /> "''"'; q '` ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I.c4}tlty,thst'6nd0r penajryt1�of pe:rJory under the Iotas of the State of California that the Information provided above Is true*rid correct.In addition,I <br /> pp1�Dara} sop atr�met id1slnf each o1 this Informr+non may result In!0od,,"�*01110M <br /> It penalties up to$25,Ot1t)per day,per violation or adminlatrative p4naliles up to <br /> $;,tfgo per vIolp I <br /> par_ <br /> ne,described In Public Res 42962.Cl1ST0M(tRPAI T;NAM!"e CUSTON TUBE DATE <br /> FSH No. 113334 .'' <br />