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j1-209-242-3051 14:08:11 07-11-2013 12/33 <br /> t <br /> V1111,11-aviv 1rI IM& C:V.y ING. �.EET SERVICE RECORD qll� <br /> U.S. TIRE SALES TPID 1000837. 165 5 6 <br /> 01 Wilson Way T7re Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US T7re Safes #24 US Tire Sales <br /> '21 N.Wilson Way 1535 Market St. 1211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Itockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95613 <br /> '09-465-0281 209.465.3262 209466.2581 209-571-5611 510-887-1282 916-395-2245 <br /> USTOMER it P.O.# DATE <br /> � s -��11 r � <br /> PHONE VEHICLE# <br /> LICENSE# <br /> OCATIO SERV4rESTATE ZIP CODE <br /> ar�G -7 <br /> psi <br /> CUSTOMER TPID DECAL# <br /> 1 certify that under penalty of perjury under the laws of the State of Cellfomla that the Information provided above Is true and correct.In addition,1 am aware that falslflcat�b ct <br /> this informationIU result In suspension,revocation,or donial of reneWal of the Waste Tlro Hauler Registration pursuant to Public Resources Code section 42960 and.rmay <br /> resut In civil pe 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 A2962 ' <br /> RIVER NAME / DRIVER SIGNATURE DATE <br /> U X h.+ <br /> CUSTOMER •R • <br /> AKE TRUCKTFRAILER# <br /> LICENSE STATE ODOMETER/HUB- <br /> �4't'i�.`A+'y`.`°� � Qr-. ••LJ� �:�: Ch1 i •✓31� Il.: t i���! 5� .0'a. <br /> -�� � XN?•1.�+-r.F1��:'{i�t t'Ysnr eti 5 i1ti — <br /> 'S' <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 /> PRODUCT INSTALLED <br /> .3rv' ay - 1 a. t ,"{.. FINISH MILES: <br /> (~ 7 L15 START MILES: <br /> 1/ TOTAL MILES: <br /> START TIME./,'. AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH T AM PM <br /> OAD OUNT ai;x" � �,� w ,.::: a ti w�4a;:e, <br /> 4. HAULER E3tEMP1TON (F` IPE' 1GA9 "' . r_.. � vrsa� <br /> ❑GOVERNMENT ❑LEA EXEMPT OTHER <br /> AGRICULTURE ❑COMMON CARRIER/B CK HAUL <br /> ICK UP LOA ;TRS <br /> ❑ IMPORT FROM " <br /> ] DELIVERY HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO �' VOLUME CUBIC YARDS <br /> -� ❑ ❑WEIGHT IN TONS <br /> Doi I cerci hat u er penalty of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,1 <br /> '90� A, am war t falslflcation of this Information may result in civil penalties up$25,000 per day, per violation or administrative penaltie's!tp to- <br /> 3 .000 r�i onperdayasdescrlbedlnPubllcResources Codosectlon42962. <br /> m <br /> C U Sqm R 1117 E CUSTOMER SIGNATURE DATE <br /> 'SR No. 1 R s-rl d K PLEASE CIRCLE STORE LOCATION AT TOP <br /> Received Time Jul, 11, 2U '' 2 : 02PM No. 0711) <br />