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1-209-242-3051 14:06:17 07-11-2013 6/33��� <br /> � � .I .,q;ON;.17V y.T/RE INC.CO., <br /> U.S. TIRE SALES FLEET SERVICE RECORD_ �? <br /> (t- <br /> '1 Wilson Way ,14 TPID 1000837. 16 5 22 <br /> #02 ConnellTire 6 <br /> 'Wilson Way T/re Recap 1 <br /> 1 N.Wilson Way .1535 Market St. #21 US Tire Sales <br /> lckton,CA 95205 Stockton,CA 95205 2211 N.lMl�on Way 2600 Yosemite Blvd. #23 US Tire Sales #14 US Tire Sales <br /> T09 465.3262 <br /> 1-465.0281 SfocftonyCA 95205 Modesto,CA 95354 1915 National Ave. 6530 Franklin Blvd. <br /> 209-46&281 Hayward,CA 94545 <br /> 3TOMER 209.571.5611 Sacramento,CA 95823 <br /> 510-887-1282 916-395.2245 <br /> DATE <br /> PHONE VEHICLE n <br /> y <br /> LICENSE ti <br /> �t7AON OF S RVICE <br /> C'O STATEPC <br /> E <br /> :USTOMER TPID <br /> I� DECAL* <br /> mulrerltfI that under penalty of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,V - II <br /> FIs Information may result In suspension,revocation,or dental of renews!of the Waste The Hauler Registration pursuant to Public Resources Code section 42060 and may <br /> suit In civil penalties up to s,25,000 per day,per vfolation of administrative penalties up to$5,000 per violation per day as described In Public Resources Code sectlort42962. <br /> n,I am aware that falsl/icatlon of <br /> ER NAME <br /> DRIVER SIGNATURE <br /> X DATE <br /> TRUCKlTRAILER# <br /> LICENSE STATE ODOMETER/HUB <br /> SPECIAL'IN TRU ONS <br /> OFF <br /> __. <br /> DE5CR1PT10N OF NFORKDf?MPt1 .�,� '(� �r ..._.. _ _......_. <br /> , Tlt]N FWi]l!KCOJW9PL {j5' '1PT10NOFWORKCOMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE <br /> FLEET INSPECTION BRASS VALVE STEM(S) <br /> MOUNT/DISMOUNT(S)LOOSE <br /> AIR SERVICE ALUMINUM STEM(S) <br /> FLAT REPAIR(S) <br /> LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> LOOSE DISMOUNT(S) <br /> REPAIR MATERIAL(S) ALLIGATOR CAP(S) <br /> TIRE(S)BALANCED <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) METAL VALVE CAP(S) <br /> I <br /> • O RING(S) <br /> S - <br /> v.,..... <br /> DESC.. . <... I <br /> t� 1� •._ �{ FINISH MILES: I <br /> u STARTMILES: <br /> TOTAL MILES: <br /> - I <br /> STARTTIME:_ r/ (AMM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> AMOUNT FINISH TIME: <br /> M M <br /> HAULER EXEMPTION IFAPPLICABLE <br /> _— •�_ ❑GOVERNMENT ❑ LEA EXEMPT ? <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL THEIR <br /> UP I <br /> ❑ IMPORT FROM LOAD TYPE <br /> .IVERY 2rWHOLE TIRE COUNT (]WEIGHT IN POUNDS <br /> ❑ EXPORTTO <br /> ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ro r a e e a h`! der ponalty of perjury under tha laws of the State of California that the information provided above is true and correct.in addition,t <br /> falsification of this Information may resuft In civil penalties u $25,000 per da <br /> 000P rvl� tion per day as described In Public Resources Code section 42962. P y, per vfolstlon or administrative penalties up to <br /> m <br /> I <br /> CUST E P INT ME CUSTOMER SIGNATURE <br /> 1 <br /> 40'IPP,C21Ved Tirlle, Jul, 11, 201 ; 2 : 02PM_No, 07' () DATE <br />