Laserfiche WebLink
Eo'd %86 TS02 Et/E 60E 90:ST 900E-t-E-E3_=I <br /> WIL„SO/V Y TIRE CO., INC. LEET SERVICE RacO'R' D' ....... <br /> U.S. TIRE SALES TPID 1000837. 80147 <br /> "o1 wkso"Way Tire Wilson way Tire QOCAV JW2 Cannell Tiro #06 wilso.way fl. 1921 US TIM salla: A23 US Tire Sale-; Ow US The S.910. <br /> 221 N.Wilson Way IMS marlicir bL 2.211 N.Wilson Way 1133 W.Eleventh S1. Nod yosamirt.,Blvd. 1915 Nzracinal Ave. 0!00 F*nkkn Mud. <br /> �' .1, <br /> V5206 69_h_o Ca. 5-- � <br /> ,Co.gz.=� T� Y,11�% SZ76 Moon.ro,CA.".Zr4- C_-1-0645 GA.b16j= <br /> 209-465-1262 209-6G_2S81 20"35-4087 209574-5611 510.887.1282 816 95+2243 <br /> CUSTOMER P p, a D <br /> -7—W —C <br /> PHONE VEHICLE <br /> LICENSE t <br /> (� 08- <br /> LOC 10 OF SERVICE STATE ZIP CODE <br /> 614 <br /> IWL <br /> - DECAL <br /> CUSTOMER TPID L ej <br /> I cenity,that urrdvr penalty of pedvry under the IaWS of the State of California 03t ine informanlon provided above is true and correct.In addition,I am aware Inat falstilication of <br /> this information may recult in ausocn2lon,revocatlon,or do,,iol of renewal of the Waite Tire Hauler Rezietfation purauent to Public Ro uroor Code 2ccdom 429G0 and may <br /> result in civil pwrahivs up to 125,000 per day,per violation or 3dMirur%i70v%pcnahw*up to S5,C00 per via tion per day as cleacritied in Public R"ourcea Code:,action<91521. <br /> -DRIVER NAME DRIV I Im—o", DATE <br /> CUSTOMER VEHICLE INFORMATION' <br /> MA4 �d ,F RAILER 4 LICENSE ST TE 0001�!�TER/eH <br /> SPECIAL INSTRUCTIONS ON OFF <br /> /ON OF WORK C041PLETED QTY. GF WORK COMPLETED QTY. DESCRIP710tv OF WORK CONIPL67ED <br /> 1-6—�ERVLCCUNT/ ON HICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S) LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE 1,10UNT(S) VALVE STEM REBUILO(S) <br /> FLAT SEPAIR(S) LOOSE DIcNIOUI`(S) ALLIGATOR CAP($) <br /> REPAIR MATERIAL(S) 71PE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> F141114,11 - <br /> QTY. I -SIZE, FINISH MILES <br /> Se A- STkQ-NI.ILFS- �ASP <br /> TOTAL P41LES: ) 6. <br /> START TIME_C._�o A%'(2) <br /> ON SITE TWE: AN P1.11 <br /> OUT TIME <br /> FINISH TIME <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> E GOVERNMENT 0 LEA EXEMPT D OTHER <br /> [:1 AGRICULTURE 0 COMMON CARRIERIBACK HAUL <br /> ICK UP LOAD TYPE <br /> '!I'-IMPORT FROM M <br /> x HOLE TIRE COUNT 'WEIGHT IN POUNDS <br /> DELIVERYEXPORT TO VOLUME CUBIC YARDS El WEIGHT IN TONS <br /> I certify that under penalty of perjury under the laws of the Slate of California(hilt the-ftfeI-*kiQ *vidcd above <br /> is true andcorrect.in addition.I <br /> oac sato am'awore that w3iticatiuri of this information may result in civil penalties Up to$25.000 per r I(. I. ci <br /> ior" rninisirative penahles up to <br /> It <br /> $5,000 per violation per clay as dnLfibed in Public Resource-.G n*a 61111 <br /> • <br /> CUSTOMER PRINT NAME STObw A SI NATURE DATE <br /> FSR No. 1 A 7 -0--j ;jjj fi2FI U0Sj![rI <br /> 60 'd OT:ST 90CZ V� q;A TSCJ'z`-,_-V7,'-6CZ:X*e_� <br />