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STANDARD WARRANTY CLAIM ADJUSTMENT NO.G 6 2 1 0 <br /> 307YOKOHAMA CLAIM FORM - _ <br /> 'OKOHAMA TIRE CORPORATION <br /> MACARTHUR PLACE,SUITE 800• SANTA ANA, CA 92707 <br /> :ONSUMER AFFAIRS(800)722-9888 <br /> TOTE: DEALER MUST COMPLETE ALL NON-SHADED AREAS. SHADED AREAS ARE FOR YOKOHAMA USE ONLY. <br /> DEALER NAME ASSOCIATE DEALER OR NATIONAL CCOUNT NAME CUSTOMER NAME END USER <br /> �` f STREET ADDRESS <br /> STREET ADDRESS STREET ADDRESS <br /> I <br /> CITY, STATE,ZIP CODE <br /> CITY,STATE, ZIP CODE CITY,STATE,ZIP CODE <br /> PHONE NUMBER <br /> YOM 4A DEALER NUMBER CLAIM DATE NATIONAL ACCOUNT NUMBER(IF APPLICABLE) E-MAIL ADDRESS <br /> 0, DAY YEAR <br /> 01 ORIGINAL EQUIP ENT VEHICLE YEAR MAKE MODEL POSITION OF CLAIM TIRE(S) NOTICE TO DEALER <br /> YES NO (Please check and indicate item number) If claim is disallowed, the product will be scrapped <br /> VEHICLE MILEAGE DATE VEHICLE PURCHASED (IF O.E.) FRONT FRONT unless the box below is checked. <br /> RETURN FREIGHT COLLECT <br /> VEHICLE IDENTIFICATION NUMBER (IF O.E.) CUSTOMER NOTICE <br /> Read Carefully Before Signing <br /> COMPLETE FOR MILEAGE CLAIMS ONLY(Attach mileage certificate(s)) I hereby certify that to the best of my knowledge the foregoing statements are correct, <br /> that I am the owner of the product presented for claim and that the product-described <br /> ODOMETER AT TIRE REMOVAL was not involved in any accident,personal injury,consequential damage or other loss. <br /> I accept credit in lieu of further claim. I understand that the tire(s), detailed on this <br /> E]0­0_0_1claim,become the property of Yokohoma Tire Corporation. <br /> ODOMETER AT TIRE INSTALLATION CAR L_Jtr`-LJt—J <br /> TOTAL MILEAGE RECEIVED I TRUCK CUSTOMER SIGNATURE DATE <br /> L <br /> 9 B !0 722-, 0 ® • +� <br /> awl <br /> .p c- <br /> es <br /> La <br /> -71 <br /> tat <br /> 7 0761 <br /> W D U YTGTFtfGAL SERV ES E�NTATIVE DA E YTC CORPORATE APPROVAL DATE <br /> 7 xis' ' DEALER <br /> M-91-7014 <br />