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33 <br /> 1-209-242-3051 • _. _ • .�• 14:04:50 07-11-2013 2/ � <br /> --� L-L-s.r v1_11rlvGflG10VnU r <br /> IRE SALES I „ —7q o TPID 1000837 16 5 4 3 0 <br /> CY �j <br /> V01 Wilson Way Tire Wilson Way Tire Recap 902 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N. Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd, <br /> Stockton,CA 95105 Stockton,CA 95105 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> ?09.465-0281 209-465-3162 209-466.2581 209-571-5611 510-887-1282916-395.2245 <br /> :USTOM. P.O.# <br /> DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> OCATION OF SERVICE STATE / ZIP CODE <br /> CUSTOMER TPID �(2 � � DECAL# <br /> 1 certify that under penalty of perjury under the laws qJ the State of California that the Information provided above is true and correct.In addition,I am aware that falsification of <br /> ,this Information may result In suspension,revocation;or denlal of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result In civil pen 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 /> )RIVER NAME DRIVER SIGNATURE DATE <br /> V—A-(_Zv X <br /> • • • <br /> LAKE TRUCK/TRAILERiF LICENSE STATE ODOMETER/HUB <br /> 75`x- 1v <br /> SPE S'1:RUCTI NB ON <br /> 5 S �- b ` ��'— • ---- -- - ---- <br /> WOO <br /> QTY. DESCRIP77ON 0 .WORK CO PLETED QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEELS) O RING(S) <br /> 7R-0DjCT INSTALLED <br /> _, ;:•: 5. _, MFG DESCRIPTION FINISH MILES <br /> START MILES: <br /> TOTAL MILES: <br /> Q l START TIME: PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: PM <br /> .OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> �� ❑GOVERNMENT ❑LEA EXEMPT L&OTHER <br /> AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TY . <br /> ❑ IMPORT FROM <br /> DELIVERY - OLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ ExPORTTO ❑VOLUME CUBIC YARDS <br /> ❑WEIGHT IN TONS <br /> para I certify that under penalty of perjury under the laws of the State of Callfomia that the Information provided above Is true and correct.In addition,I <br /> am aware that falsification of this information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> c $5.00operviolatlonperdayasdescribed InPublic ResourcesCodes ction42962. <br /> � s <br /> i <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 165430 PLEASE CIRCLE STORE LOCATION AT TOP <br /> Received Time Jul, 11, 2013 2 ; 02PM No, 0711) <br />