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w FLEET SERVICE RECO �1 <br /> ilMi7b <br /> WILSON WAY TIREING, TPID 1000837. 1-757 <br /> U.S. TIRE SALESS <br /> tris us n1.s.►.. <br /> 027 US nn Safes GM F�snpin liNd. <br /> 00 021 US Tire Selo' 1015 NletlonaJ Ave. T3 2 <br /> t IW1.,.,,{r.,I)- WIN,—IYay flaw Rno,l, pot Cnnnnrl Tiro 7nnn ro,arnrro erve. Sacramento. <br /> r N Ilvfaon{Yap 1?15 Afvau,St, 2711 N.Wilson Way Hayward.CA 04545 - <br /> +x fron,C<e5705,•' Stria-Afrin.CA 95:05 Sfoch tori,CA 95209 Modesto,CA 95354 51"87-1292 <br /> Q"ZillI 209.405720: 20..9409-2581 209-5%14911 '/ <br /> P.O M GATE <br /> J.,3 L. ,/►f .. <br /> HJNE VEHICLE V <br /> LICENSER },� <br /> _ 11 - - - - ---------.-_. - <br /> 1 , <br /> STATE <br /> HT1"%,(11 SERVICE/ <br /> CUSTOMER TPID -- DECAL.# J'�{—Az <br /> _ o <br /> I Cr,t.fy thus under penalty of penury unit•,thn lays of the Stale of California that the Infomatlon provided above Is trite end correct, <br /> [,, ;n',, 1.+n may reeult In suspension,revocation,or denial of ranowal of the Waste Tire Hauler Registration pursuant to Pu61{G IteputC0l,t:Cde <br /> -vaut In,,-Inm <br /> 1 pelNea up to$25,000 par day,per violation of administrative penalties up to S5,00)1Par violatlon per day as desCAbad In PubltGDttef7itlrC <br /> DRIV S A�14 � <br /> .. <br /> _.i <br /> yhr TRUCKITRAILER# LICENSE STATE -. OODM Q <br /> I <br /> SPECIAL INSTRUCTIONS ON <br /> - <br /> . <br /> fly' I DESC'i-'P 7, aV OF WORx COMPLETED OTY DESCRIPTION OF WORK COMPLETED OTY i)DE5- d, <br /> S ER\i'.CE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> 71 INSPECTIONMOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> =L-IT REPA!R- S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> ._P jR t.'ATERIAL S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> i <br /> 'TC'?;5) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT INSTALLED <br /> .S;ZEI MFG DESCRIPTION FINISH MILES: <br /> Pie <br /> � START MILES: <br /> r <br /> TOTAL MILES: <br /> _ � Y <br /> START TIME_ AM PM <br /> T�— <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM P1J <br /> FINISH TIME: AM Ptd <br /> +D�"+D A MOUNT HAULER EXEMPTION IF APPLICABLE ='•; <br /> _ <br /> J ENt,tAENT LJ LEA EXEMPT ❑OTHER <br /> J <br /> �- �!Jt.TIJ- - I ❑ Co kIMON CARRIERIBACK HAUL <br /> -�� <br /> LOAD TYPE <br /> - ]WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> y order th9 I.1w11 Ihn S•+.ate of aliforn!a that the information Provided above Is tmo and correct in adrll <br /> ,rf,r,naflr,n m.{y result in civil D*nalllp'% Up 125,000 tier day, per violatlon or admintstraRtve pensttiea <br /> . .. � � ,'l " ly+'l In i"ulrlir.Gjc�r.urc�!rrx71.tt4ti14n A291i2. <br /> t i <br /> :::I: Ct1S fUMf_Ft SIGNATURE DATE <br /> i <br />