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AP r. 24. 2008 2:44PMSO7lrCr" �iLi TIRE=GO.LDEN IfTATE TRUCK No. 6481�EG�P:._5 <br /> VVILU.6. TIRE ACS j'pjp'.' Q0837'::' ' , 9054 <br /> i.�,.. d''��' V�,�sr 3fn Sllh <br /> r' ,,n1 a '"r*Sons <br /> Mol Wilson way Tire Wilson Way Tire Recap A02 daft Kra /08 lNBson.whY Ohs. N2f:.ff6 a <br /> 221 N.Wilson Way iS38 Market St. 221`''.Wilson WAY 1199 W.Eleverrlft 5t. 3811DP1yosa+nlre$tom f �SiSlv9lliapplllve $59bFrr•Axlln 8lvd- <br /> fYtecxton,Ca.9520 stoektoty ca.98305 xlon.CA.9lf8oi hacy;Co.OMB Modesto.':'W"'` i'..1faYN+d,'C.A.spfSQ�'' $pokalflBMO,CA-9023 <br /> 208+795-0291 209.4665.3262 a '-420g4W b61 20043E+1087 204671681! 510887-l3$2 B1F991�2245 <br /> SCJ <br /> CUSTOMER PDATE <br /> .O.# �.- J,`" '� � •,J � S ...T <br /> ` �xp... �p .`. d /t,.rl \• fes••':M.. Lp.i' <br /> PHONE VEHICLE <br /> f <br /> LICENSE# <br /> LOCATION OF SERVICE f C $ STATEfrrZIP CODE <br /> CCUSTOMER TPID L ru�_-� �_ _ - _L ;.I <br /> `�L___�T,. ? _____1 <br /> I certify that under penalty of polurll under the laws of the State of Califotnla that thetltlormatits provided oala Ist a 3rEot�tdit t il�t'h t7 vAtldn.42at falsification amayof <br /> this InlormaUen may result In suspinslon,revocation,of denial of renewal at the Waste The HeJdrRegiatrld "pc.; :fb I�Tib�k' sai�rc'e�@totTa,se�tlo�t 42960 and may <br /> result in civil panaltles up to$28,000 per tray,per violation or administrative penalties up to S5,o0o par vlol#IfaH piA'r,ds site ilbeHH.)ll(pan1R1H9`tAur6es Code SecUen 42982. <br /> DERIVER NAME 1 DRIVER SIGNATURE <br /> x r' <br /> "? DW&1•FVHUB <br /> M�Kg— <br /> "'b <br /> K/TRAILER# LICl;NS > Ti�Te�E'SC: <br /> 5RVIC �� L rM•UNT/DISMOUNT(S)ON VEHIC K J `BFIASS,VALVE STEM(S) <br /> S, ,. : S) <br /> FLEET INSPECTION MOUNT?DISM4WNT(S);CQC3SE .i;:.�;` �;, ;, ,AEU.WNUM STEM <br /> AIR SERVICE LOOSE MOU4) <br /> FLAT REPAIRS) LOOSE DISMOUNT($) t t i J �'dlifKlt�ATf�R AP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED rMFTALsllALUEnCAE?(S), <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(•5) <br /> �'-`. } FINISHMILES1 <br /> ";TZ1" 4)1 SAY7 TRT MILES' •` <br /> TOTAL MILESE <br /> START TIME: "" AMn�,✓A <br /> ON SITE TIME; AM PM <br /> OUT TIMI:; AM PM <br /> FINISH TIME: Afi PM <br /> ".fr� 'Jfy � f ; Y4�1"1sF��i ..��yi�j ' { ♦tea,' { gllt�{'r.'11, ; J,; r�;JY,1Ga:f"�,Fi',f'�'���ii�:}r,F�'. <br /> LOAD AUNT <br /> — ❑ GOVERNMENT ❑ LEA EXEMPT, I ❑'QTHEIR <br /> -- 0 AGRICULTURE CI COMMON CARRIER/BACkkAUL <br /> F-1PICKUP <br /> ❑ IMPORT FROM W �",)lfi�IN POUNDS <br /> ❑ DELIVERYs >�E164 IN TONS <br /> Cl EXPORT TO [I VOLUME„CIBIC.,.YAf ,',._... <br /> I certify that under penalty of perjury urndor the Jaws of the State of Cefiforri18 that ttit►trilot�i[lRtfi;lpMftet abtrva'Is true and correct.In addition,I <br /> �c PQb, am aware that falsification of this Information may result In civil,penalties.up to$�5 aoaa per 4y;.per vW(bitldh or administrative peneltles up to <br /> So ' 6#,000 pot violation per dpa <br /> Ay as described In Public Resoura ,Code section 42962 :' i,r <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 10- a <br />