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ET SERVICE RECORD <br /> r_ WILSON WAY 'PRE CO.,CO ,�1 ������ � <br /> U.S. TIRE SALES ��� f � T D1000837- 156775 <br /> #2 S Tire Sales #24 US Tire Sales <br /> #Ol wlson Way Tire Wilson Way lire Recap 222 Nn�s Tire <br /> 2600 YosemTire itelBlvd. 915 National Ave. 6530 Franklin 81vd- <br /> 221 N.Wilson Way 1535 Market St, ya ard,CA 94545 Sacramento,CA 95823 <br /> Stockton, CA 95205 Stockton,CA 95205 Stockton,CA 85205 Mo 0, 510 87-f 282 916395-2245 <br /> 209-466-2581 709-571.5611 <br /> 209-465.0281 209-465-3262 DATE <br /> CUSTOMER P O # <br /> PHONE VEHICLE# <br /> LICENSE# <br /> Lv �� a ) <br /> STATE ZIP CODE <br /> LOCATION OF SERVICE <br /> CUSTOMER TPID / ' J777 <br /> gEGAL# JJ <br /> ----- , — <br /> I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct In ounce n,l de aware that 50 an mayation o s <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauier Registration pursuant to Public Resources Code section 42960 and may <br /> resutt'in civil penalties up 40$2$,000 per day,per violation of administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SIGNATU <br /> X 't <br /> i; <br /> TRUCK(TRAILER# �L1 LICENSE <br /> // STATE ODOMETER/HUB <br /> MAKE Y V�� <br /> �Y� <br /> SPECIAL INSTRUCTIONS ON OFF <br /> CAPS <br /> eZ>.4/3,,D <br /> C?7 DESCRIPTION OF tVORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY DESCRfPT10N OF WORK COIv1PLFTEA <br /> SERVICE CALL '„� MOUNT!DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION <br /> MOUNT!DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE <br /> LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) <br /> LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) <br /> TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S). RECONDITIONED WHEEL(S) . O RING(S) <br /> e a FINISH MILES: 1 <br /> QTY 5 MFG <br /> START MILES: <br /> a <br /> 4/4/o <br /> TOTAL MILES: <br /> STARTTIME:_S )--- PM <br /> ON SITE TIME: PM <br /> OUT TtME:1z----346PM <br /> FINISH TIME: Zr?a AM <br /> HAULER EXEMPTION IF APPLICABLE <br /> LOAD AMOUNT U OTHER <br /> ®GOVERNMENT ❑LEA EXEMPT <br /> _ —-C�o — C4 AGRICULTURE ❑COMMON CARRIER/BACK HAUL T,i <br /> ` LOAD TYPE <br /> PICK UP WHOLE TIRE C„OU T ❑WEIGHT IN POUNDS <br /> Q IMPORT FROM <br /> DELIVERY ❑VOLUME CUBI P1RDS ❑WEIGHT IN TONS <br /> (DEXPORTTO <br /> I certify that under penalty of perjury under the taws of the state of California that the into ' ^Pr ided above Is true and violaf on or administrativecorrect, <br /> estop <br /> o��c Daly r i a are that falsification of this information may result in civil penalties up$25,00 p, P <br /> s Q 0perviol ion per day as described In Public Resources Codes -on 42962. <br /> DATE <br /> • USTOMER P NAME CUSTOME <br /> ,,n <br /> C C-1-1nr IAT-i-L <br />