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�1-209-242-3051 14:07:15 07-11-2013 9/33ry, <br /> �y 3' • ' . <br /> U.S. SIRE SALES 1rVy. •til DtKV16t KMILIKU 1(L(1'l <br /> �� <br /> 7 TPID 1000837 16 5 5 0 4 <br /> bi <br /> 11 Wilson Way Tire Wilson Way Tire Recap 402 Connell Tire #21 US-Tire$ales 023 US Tire Sales #24 US Tire Safes <br /> ?1 N.Wilson Way 1535 Market St. 2211 N.Wilson Why' 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> fockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto, CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 79465-0281 209-465-3262'Cl209 d66-2581 209.571-5611 510.887-1281 916-395-2145 <br /> JSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICr <br /> )CATI F SER ICESTATE ZIP CODE <br /> 1 - <br /> ., _� <br /> CUSTOMER rthat er penalty of peury under the laws of the State of California that the Information provided above is true and orrecLIn addition,I am a <br /> ware that and <br /> of <br /> this Information may result in suspension,revocation,or denial of renewal of the Waste Tiro Hauler Registration pursuant to Public Resources Code section 4296060 and may <br /> result In civil p los up to$25,000 per day,per violation of administrative penalties up to$3000 per violation per day as described In Public Resources Code section 42962. <br /> 21VER NAME DRIVER SIGNATURE DATE <br /> _k <br /> X <br /> CUSTOMER •' • <br /> WE TRUCKrrRAILER# LICENSE STATE ODOMETER/HUB <br /> SPE ' L' INSTRU TIONS O OFF' <br /> j�lw -7 1 w 7 - - -- --- -- ----- ---- - <br /> CITY. DESCRIPTION OF WORK COMPLETED Q .DESCRIPTION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMP.LFIE'A - <br /> SERVICE CALL hiT(bU�1T/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNTS) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(8) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> fTY _,•,... l MSO DESCRIPTION FINISH MILES: <br /> !J START MILES: <br /> TOTAL MILES: <br /> START TIME: Phi <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM <br /> DAD AMOUN ";:, r. HAULER EXEMPTION IF APPLICABLE <br /> (3GOVERNMENT (J LEA EXEMPT THER <br /> +++"' AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ] PICK UP LOA TYPE <br /> ❑ IMPORT FROM 6 I . <br /> ]DELIVERY HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORTTO ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> pard I certify that and r I}enalty of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,I <br /> od am aware at fa Catton of this Information may result In civil penalties up 525,000 per day, per violation or administrative penalties up to <br /> $5,000 per latio rdayas described In Public Resources Coda section 42962. <br /> m <br /> CUSTOMER PRIN AM CUSTOMER SIGNATURE DATE <br /> :SR No. 165504 PLEASE CIRCLE STORE LOCATION AT TOP <br /> Received Time Jul. 11. 2013 2 : 02PM No. 0719 <br />