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1-209-242-3051 14:09:17 07-11-2013 15/33 <br /> 41 • r %,F .. -LCCI OtKV16t Ktl'UKU Q�I <br /> U.S. ,IRE SALES _� ';, M54C �`TPID 1000837° 16 8 4 9 ' <br /> 1 Wilson Way Tire Wilson Way The Recap #02 Connell Tire 5 Tiro Sales23 US Tire Sales <br /> 221 N.W7/soq Wa 1535 Market SL ,., i 1124 US Tire Sales <br /> X 2211 N.Wilson Way Oyosemits Blvd. 1915 National Ave. 0530 Franklin Blvd. <br /> Stockton,�95Wj Stockton,CA 95205 Stockton,CA 95205 Mod6to,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465-0281. " • 209-465.3261 209-466-2581 209.571-5611 510-887-1282 916-395-2245 <br /> :USTOMER P O # <br /> DATE <br /> PHONE VEHICLE# <br /> LICENSE IF <br /> OCATI tyP`.sE ICE STATE ZIP CODE <br /> bd <br /> CUSTOMER TPID DECAL# <br /> 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 am aware that falsification of <br /> this Information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42900 and may <br /> reript l�l�vll pe a up to$25,000 per day,per violation of administrative penalties up to$5,000 per violation per day as doseribed In Public Resources Code section 42962, <br /> IR11(ER;NAME DRIVER SIGNATURE — <br /> DATE <br /> x- <br /> 151.2tolkyAl 21-11110T214",lei 1111C1111111,14 <br /> alum 0 <br /> IAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> OF <br /> cs `�`� � -------- — -- -. -- - ---- <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 REBUILDS) <br /> 'FIAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAf(S)7 <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> FINISH MILES: <br /> '��'tsalt�Tl�fS7�1: <br /> X START MILES: <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: qM pM <br /> OUT TI ME: AM°PM <br /> "- FINISH TIME• AM PM <br /> OAD AMOUN`f-. �� .4 � "vt :'' L xx 1«' <br /> Q GQ>3E�RNMENT' .,tiA�lj :.F w_o: <br /> �7p <br /> ❑LEA EXEMPT THER <br /> ❑AGRICULTURE Q COMMON CARRIER/BACK L <br /> " ❑ IMPORT FROM TIRE COUNT <br /> .DELIVERYQ WEIGHT IN'POUNDS <br /> !i�, El EXPORT TO 1 F&M&OLE <br /> VOLUME CUBIC YARDS Q WEIGHT IN TONS <br /> I eartify that under penally of perjury underthe laws of the State of California that the Information provided above is true and correct,In addition,1 <br /> am aware that falsification of this Information may result in civil penalties up$25,000 per day, per violatlon or administrative penalties up to <br /> 7 vii i"� $5000 violation per day as described In Public Resources Code section 42962. <br /> r0. Cl1tT P _ T NAME CUSTOMER SIGNATURE DATE <br /> � R No. 468" 69 PLEASE CIRCLE STORE LOCATION AT TOP <br /> , <br /> ���_ . � V TI �r_ 1, 11, 21.113 2 02°M No, 0711) _ <br />