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1-209-242-305114:33:57 10-29-2013 3/4 <br /> Wit-SON 1`:TIRE Co. <br /> INC. Z ,`{�t�/ <br /> FLEET SERVICE-RECORD <br /> .. U.S. TIRE SALES TPlD 100083t.' 1-261-54� <br /> 001 wagon Wayne Woad war Tiro Recap OW Conwif TLs <br /> 22r AL Wagon way . •rasa Yatket Ss. roe 1 wry Tfns szr rt>r 7be Sales a2 Us 7Ls Sales. Ise Up TIM 9Ylw <br /> > Ca; Efec fi wason way 1133 W.t7ip.,f6 st anuo l/oornMa Blvd' ral9WatlerWAVAL B <br /> ;ins.rmq,Ca.sBPtxf titool:ter4 Ca trot! %wev,!k Stays ` <br /> r 1m, Modaror t o 1i64a4 x.,•MT. c.w6fs, s.ot.n,ant,,CA traa�t <br /> parr`, aoas�raerr sraaaT.raaa e16.9vszia4a <br /> CUSTOMER P.O. t# DA <br /> • PHONE VEHICLE <br /> r <br /> LICENsg 4 <br /> In <br /> LOAq <br /> CATION.OF SE VICE I STATE <br /> l • . : . ZIP`CODE <br /> V <br /> CUSTOMER TPI DECAL#t <br /> 1 certify that under penalty of penury under the laws of the State of California that the <br /> Information provided above to true and correct in adallion,!am swam that.latetflea <br /> this Information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler.Reglstration pursuant to Public Resources Code section 42960 and ma <br /> "� <br /> result In civil penalties up to 125,0W,per.daV,per violation or administrative panatill"up to 16,000 per violationr <br /> pe day an described In Public Resources Code section 42982. " <br /> DRIVER E s' DRIVER SIGNA RE DATR <br /> X • ' <br /> MAKETRUCKITRAILER## LICENSE . STATE ODOAgETERII(Ufa <br /> n Cao acoa,a, i- ---- --- <br /> Fw_ <br /> 3 � . <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET'1NSPEDt1ON NIDUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S)' <br /> AIR SERVICE LOOSE MOUNT(S) . VALVE STM REBUILDS). <br /> FLAT.REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAtR MATERIAL(S) TIRES)BALANCED METAL VALVE CAA S) <br /> WHEEL SWfTCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> Willi FINISH MILES: <br /> STARTMILES:77 . <br /> _ I� <br /> i <br /> TOTAL MILES: <br /> r START TIME .-" ' '•' :Au M I <br /> ON 81TETIME: Ale?M . <br /> r , <br /> OUT TIME �sni ru <br /> FINISH TIME: Aaq <br /> .OAD AMOUNT r . 1E <br /> O GOVERNMENT D LEA EXEMPT.. 0 OTHER. <br /> ❑AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP t <br /> ❑ 1MPORT FRAM <br /> DELIVERY. WHOLE TIRE COUNT p WEIGHT IN POUNDS <br /> ❑ EXPORT To. . �l ❑ VOLUME CUBIC YARDS: ❑ WEIGHT IN TONS <br /> t DatQ�. I certtfy.that under'ppnattyof.penury under the laws of the I¢of Callfornla that the informativripruvided ebove'l■true and e0rtsct in sdditlan,I <br /> am ewaro that Tnlelflodtloa of this Inlorrnetlon may raeult In vIi penalties up to 125,000 porde <br /> 15,000 per vlolation per day as described In Public Resources Code saetion 42062 yl °.vlofation 4r Sdminlstrettva psnettlss ftp to. <br /> . _ <br /> `.CUSTOMER.PRIN1 NAME CUSTOMER SIGNATURE <br /> SR No: 126"154: ... .DATE. <br /> Recelvea Time Oct, 29. 2013 2 . 29PM No. 0862 <br />