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4:07:34 07-11-2013 <br /> �-�29-242-3051 1 ` 130 _ , ., � %01%.r.1 #I• CC1 CIERVIUr. KCkoUKU � <br /> U.S. ►,RE SALES /� � <br /> 1 TPID 1000837. 16 5 5 0 <br /> 11 Wilson Way Tire Wilson Way The Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> !1 N.Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> ockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward, CA 94545 Sacramento,CA 95823 <br /> 19-465-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> 1STOMER�n � P.O.# DATE <br /> l/� — e7- <br /> PHONE VEHICLE# <br /> LICENS <br /> iCATI OF SE VICE STATE ZIP CODE <br /> CUSTOMER TPID�L i DECAL# <br /> I certify that under permay of perjury under the laws o6the 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 donial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> rosult In civil penalties 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 /> LIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> • OR • <br /> KE TRUCK/TRAILER# LICENSE STATE ODOMETERIHUB <br /> SPECIAL INSTRUCTIONS 6N OFF <br /> Arm ifs - <br /> OTY. DESCRIPTION OF WC kt(COMPLETED 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 WHEEL(S) O RING(S) <br /> ESCRIFINISH MILES: <br /> DPPON <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME_. _ �AM t <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AAl <br /> OAD AMOUNT ' , HAULER EXEMPTION IFAPPLICABLE <br /> ❑GOVERNMENT (3LEA EXEMPT OTHER <br /> i - ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> ❑ IMPORT FROM_ <br /> DELIVERY WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORTTO ❑VOLUME CUBIC YARDS <br /> ❑WEIGHT IN TONS <br /> NQ Dotp 1 certify that under penalty of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,I <br /> `o :Q am aware that falsification of thlsJnformation may result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> e G $5,000 perviolatlonperdayasdeseflbedlnPubllcResourcesCoda sectlon42862. <br /> m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> =SR No. 165505 PLEASE CIRCLE STORE LOCATION AT TOP <br /> Received Time Jul- 11, 2013 2: 02PM No. 0719 <br />