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�~ Vf/ILS®IV VI/AY TIRE CO. i1iC. ENTER—D EET SERO E RECORD <br /> e alas/�� <br /> U.S. TIRE SALES. TPID 10 37. 156763 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire 921 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton, CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465-0281, 209-465-3262 209-46¢-2581 209c571-5611 51,0-887-1282 916-395-2245 'f <br /> CUSTOMER P.O.# - DATE ryry 2 / r <br /> PHONE VEHICLE# I_ <br /> Il <br /> LICENSE# <br /> Uqv6ot —2 <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID 3 �/ g 7 p DECAL# f �— <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 addition,I am aware that faisificatlon of <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result in civil penalties up to$25,000 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 SIGNAT DATE <br /> XCUSTOMER VEHICLE-INIFORrOA�i ON <br /> -a�-�(} <br /> MAKE TRUCKMRAILER#� �^'( LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> =d A FAJ�'Y dP?3 art,24C?.? - <br /> QTY DESCMP OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT I 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 REBUILDS) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIALS)..5 TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH 4S): ' .' RECONDITIONED WHEEL(S) O RING(S) <br /> �.� TALLED <br /> . <br /> SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME:�Q ���PM <br /> ON SITE TIMEZjn�%C I�PM <br /> OUT T IME AM PM <br /> FINISH TIME:-Teo P <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ��• �3t ❑GOVERNMENTQ LEA EXEMPT Q OTHER <br /> X� ❑AGRICULTURE, Q COMMON CARRIER/BACK HAUL <br /> 2JCK UP C� LOAD'TYPE <br /> RT FROM 1Qf� id ❑WHOLE TIRE COUNT Ll IN POUNDS <br /> DELIVERY ^ ` <br /> ❑ EXPORT TO Z:z tV �� 0 ❑VOLUME CUBIC II RDS ❑WEIGHT IN TONS <br /> ,c Dcro L certify that under penalty of perjury under the taws of the State of California thats a inform h provided above is true and correct.In addition,I <br /> `po Tr ware that falsification of this information may result in civil penalties up-125,00 • y,per violation or administrative penalties up to <br /> 5 perviolationperdayasd ribedinPublic Resources Code section429 <br /> o � <br /> • <br /> gST ER RI NAME CUSTOME 1 DATE <br /> FSR No. 6 3 'PLEASE CIRCLE STC ?CAON AT T,-`n <br />