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Apr, 24, 2008, 2
<br /> Y 4 " ELL TIRE/GOLDEN STATE TRUCK 6481 P. 6
<br /> : PM C 1 �'U No,AY TIR G7
<br /> >C ., INV. FLEET brmvn,c REC%#ttLF
<br /> us.: TIRE SALES
<br /> TPID 1040837. 108918
<br /> W09 Wilson Weir rin YY1t;on Wdy T7ro,rocas aD4't cA1YA11 T7re""' Y0s Wilson'way Tiro 01 US Tfre Safes N2J US Tire Sal@s #24 US Tire Baha
<br /> 221 N.wiileon Way 1595 Market St. 421 f N.Wilson Way 7 f93 W.ilgventh St. 4460 yesemft HTML f$T5 Natianaf A,re. 8890 otent Franklin A.9
<br /> S11jakiart,Co.952-06 5t9cMon,Ca.$5205 Stockton,Ca.85405 Traay,Ca.$SMY6 A%d"t0,CA.Wild Haywardr Ce.$4549 Sacrart 224 CA.95$39
<br /> 20846"201 2o9a68am 20444&2961 209. aS41487 407677.5671 810-M74M2 8763968245
<br /> CUSTbMER-V�IAMt7tJD 1) �� P.O,# DATE
<br /> E '
<br /> PHONE VEHICLE# 9
<br /> LICENSE#
<br /> LOCA N OF S VIG ;3` �i:..'A� `? STATE ZIP CODE
<br /> DECAL#
<br /> CUSTOMER TPID �'..'J .. e 1 f i1 :',:,,e
<br /> 1 certify that underpartsny.efsp ijutryiurttie[ttiMfsws of.fN Stat9.oFG''alttornle Chat tit$information provided above is trod and correct.In addition,I am aware that fewficatlon of
<br /> ibis information may,ry#ult in AuapersjoQ,reV61wA44e+1,'orytiahiaLpfYrAewal of Ihe,Vya$to Tire Hauler Registration pumuont to Public Rosources Code geCtlon 42980 pntl may
<br /> result In Civil penalties up t0 S25,OD0�elr tl,Qy i9t Y(o18�fon,ot.edmif�iSMeUve penOaQ up'to S5,t)op per violation per day as described in Public Resources Code section 42962-
<br /> DRIVERA QRIVER SIGNATURE DATE
<br /> X
<br /> WE TRUCK/TRAILER# LIG�NNSE STATE ODOMETr=PJHUB�•r u ty Irl - �h � r v' wi<� tr`j•sr<`t"-.'4.in, st ir & ,
<br /> ,.i�eX•wt:� '.. .��:9�,'y'i'r���1tK' � :��INS'� `7�f�5�'.C� i,.a ,l Ik},. t��,�..7 � t�.,'5� ,�,{..:.e. ��'""1�"1V� `rC.a,�Y.. ��''�I. �,; r ;r; '6:� .�'�? t
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<br /> t '> 3;c. a sip ol4![IG',li�p4'E7' �1 ' u y b >1P�F��i7Favv6gA�1 l; req
<br /> SERVICE CALL..._,,... 1._,... .,., MOUNT I DISMOUNT($)ON VEHICLE BRASS VALVE STEM(S)
<br /> FLEET INSAECT(0)3',ti p('., ::'.;;C.s", MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S)
<br /> AIR SERVIGE;, VALVE STEM REBUILD(S)
<br /> FLAT REPAIRS) ti, .i. < ! I OOSEiDI fy O.UNT{$)1 ALLIGATOR CAP(S)
<br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP($)
<br /> WHEEL SWITCH(S) s'•'•:, ' ?;;'' '°';;RECONgITIONEp WHEEL(S) 0 RING(S)
<br /> q<. FINISH MILES;
<br /> gS �,'� START MILES:
<br /> TOTAL MILES:
<br /> START TIME: tit M
<br /> ON SITE TIME: Ant Pts
<br /> OUT TIME: Ane PM
<br /> FINISH TIME: tl >( pM
<br /> 7,.•� T� t :;r�,� ,"G' � '� > C• "�r.r
<br /> LOAQ
<br /> MW b ,f�(�Sb �,. ,�Y; ealu Y�dA
<br /> �? 1,
<br /> d b ❑, ERNMENT- ❑ LEA EXEMPT ❑ OTHER
<br /> ❑;;AGRICULTURE ❑ COMMON CARRIER/BACK HAUL
<br /> ❑ PICK UP
<br /> ❑ 1MPORT.FRONQ ;:r y ui, r «' >' y {:t; 4 P°" ❑WHOLE TIRE COUNT ❑WEIGHT IN PQUNDS
<br /> ❑ DELIVERY •
<br /> Cl EXPORT TO ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS
<br /> e c ceetlry that under'penall of Pe Nry under the laws of the State of Califprrtia that the Inlormatlon provided above Is true and correct-In addition,I
<br /> ,rn awara that t4I4ificy6on,6f this lnfarmatlon may result In elvil penalties up to$25,000 per day,per vw;ktlon or adminlatretive penalties up to
<br /> S5,001)pet violation per,dfiy ae,dgac)shed in Pu41is:Rvaourees Code settlors 42982.
<br /> 1
<br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE PATE
<br /> FSR No. 1.08918
<br />
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