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1-209-242-3051 14:09:47 07-11-2013 16/331 <br /> i ' , t r r VVIL- 7VIv vvl' 11I1L vv.f 11V%/. .ter v�.r..rv�r.wvr.v g�G�l� <br /> U.S. 'l iRE SALES <br /> (n� TPID 1.000837. 16 8 4 8 9 <br /> Wilson Way Tiro Wilson Way Tire Rocap 002 Connell Tire #21 US Tire Sales #23 US 77M Sale- #24 US fire Sales <br /> N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin BIVd. <br /> *ton,CA 95205 Stockton, CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> •465-0281 209.465-3262' 209.466-2561 209-571-5611 610-887-1282 916-395-2245 <br /> iTOMER P.O.# DATE <br /> PHONE VE CLE# <br /> -r <br /> LICENSE# <br /> :ATIO F.SE ICE STATE ZIP CODE <br /> CUSTOMER TPID -_ "'f — DECAL# <br /> certify that under penalty of perjury under the laws of the Stale of California that the Information provided above Is true and correct..Injaddition,I am aware that falsification of <br /> this Information may reeull:In suspension•revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result In olvll penalties up to$26,000 per day,per violation of administrative penaltles up to$5,000 perviolation per day as described In Public Resources Code section 42962. <br /> IVER NAME DDyRIVER SIGNATURE DATE <br /> CUSTOMEP VEHICLE INFORMATION <br /> KE; TRUCK/TRAILER-4 LICENSE?12 STATE ODOMETER/HUB <br /> q r•t <br /> / 2 <br /> rv6Q <br /> NMI <br /> . SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEMS) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MAT�RIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> FINISH MILES: <br /> F <br /> -� START MILES: <br /> TOTAL MILES: <br /> START TIME: AM,(p <br /> ON SITE TIME: AMS PM '+ <br /> OUT TIME: AM Prwf <br /> e -.. <br /> FINISH TIME: >AM hA <br /> D AMOUNT <br /> Q GOVERNMENT ❑LEA EXEMPT Y THER <br /> — — AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> r i�• U-IMPOkTFROM HOLD TIRE COUNT ❑WEIGHT IN,POUNDS <br /> DELIV�Y��t'" - ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ❑ EXPORT,TO '. i <br /> I certify that and r penalty of perjury under the laws of the State of California that lha.lnformallon provided above Is true and correct.In addition,l <br /> c DOtp�' em aware that falsification of thlq Information may result In civil penalties up 525,000 per day,per violation or administrative penalties up to <br /> $5,000 pervlolation per day as described In Public Resources Code seciforTA2981( <br /> CUSTOMER PRINT NAME CUST0M'[f"(GNATURE DATE <br /> FSR-NO. 168489 LQ PLEASE CiRCLE_STORE NfION AT TOP Y <br /> Received Time Ju . 11 2013 2 02 0719 <br />