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1-209-242-3051 14:08:40 07-11-2013 13/33 <br /> ""' I Wk GUy INC. _EET SERVICE RECORD qp�l3 <br /> U.S. TIRE SALESj bI p5�gTPID 1000837. 16 5 5 48 <br /> o lS� (� <br /> on Way Trre Recap #02 Connell Tire #21 US Tire Sales 923 US Tire Sales #24 US Tire Sales <br /> X535 Market SL 2211 N.Mason Way 2600 Yosemite Blvd. 1915 NationalAve. 6530 Franklin Blvd. <br /> Sfockfon,CA 95105. Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95623 <br /> 209-465.3262 209-466-2581 209.571-5611 510-887-1282 916-395-2145 <br /> CU S P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> )CATIO F SERKE �-- STATE ZIP CODE <br /> CUSTOMER TPI <br /> I certify that yn ;� <br /> der penalty of perjury under the laws of the State of California that the Information provided above Is true and correc- in addition,1 am aware that falsification of <br /> this infojmatlon may result In suspension revocation,or denial of renewal of the Waste Tlra Hauler Registration pursuant to Public Resources Code section 4296D and may <br /> result In civil penalties up to$25.00 A, per viola% h ojypdminlstrative penalties up to$5,000 per violation per day as described In Public Resources Code section 42962. <br /> DIVER NAME _ _s DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER • • <br /> WE TRUCKfiRA{LER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL fN •`@-�S`:: - , ON OFF <br /> � r <br /> t34'Y UE5t?RIJy770NOr WORK COMPLETED Q7>! DESCRIPT/0N OF WORK EOMPI-EYED QTY. DESCRlPT1ON 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 /> PRODUCT • <br /> SI MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: r AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIM — AM PM <br /> DAD AMOU nSIC/- HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑ LEA EXEMPT OTHER <br /> ❑ GRICULTURE ❑ COMMON CARRIER! ACK HAUL <br /> ICK UP <br /> LOAj6 TYPE <br /> ❑ IMPORT FROM _ <br /> ]DELIVERY WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO " ❑VOLUME CUBIC YARDS LJ WEIGHT IN TONS <br /> c Dafo 1 ce I t t under penalty of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,1 <br /> am lawate'Mat falsification of this Information may result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> $5, Op rvi atlonper day asdescribed InPublic Resources Code section 42962. <br /> m <br /> CUSTOMER I AWE CUSTOMER SIGNATURE DATE <br /> SR No- 1 P I; �A Q P1 FQSE CIRCLE STORE LOCATION AT TOP <br /> received Time Jul. 11. 2013 2 , 02PM No, 07111 <br />