Laserfiche WebLink
KSO&, Y TIRE CO., INC. FLEET SERVICE RECORD <br /> U.SWIIRE SALES <br /> TPID 1000837• 125130 <br /> Wilson Way Tire Recap #02 Connell Tire #05 Wilson Way Tire , #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> ay 1535 Market St. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> ai 95205" Stockton,Ca.95205 Stockton;":Cas 95205 Tracy,Ca."95376 -Modesto,CA.95354 <br /> Hayward,Ca.94545 ::Sacramento,CA.95823 <br /> 5-0281 209 4653262 209 <br /> -466-2581 209-8354087 20957"14617 510887.7282 916395 2245 <br /> CUSTOMER - P.O. # DATE <br /> PHONE VEHICLE # / <br /> LICENSE # <br /> LOCATION OF SERVICE _1z STATE ' ZIP CODE <br /> CUSTOMER TPID � I DECAL.# J <br /> 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 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 42960 and may <br /> result in civil penalties up to$25,000 per day,per violation or administrative penalties-up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAMEDRIVEf,-SIGNATURE DATE -- -l� <br /> r x J' c ; <br /> CUSTOMER VEHICLE INFORMATION <br /> MAKE TRUCKZRAILER # C. LICENSE; r_. ST TE '—ODOMETER/HUB <br /> .SERV"ICE CALL.-� MOUNT/DISMOUNT(S)ON VEHICLE) RASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> t 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 /> • l ,. . 117 . D. ( ( ., FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> /f START TIME: AM-PM <br /> ZZY ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT52 <br /> ? F# SMP?IQ:Nk� ..zE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> -- -- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑ PICKUP COpDaYP. <br /> ❑ IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ❑ DELIVERY <br /> El❑ EXPORT TO VOLUME CUBIC YARDS ElWEIGHT IN TONS <br /> I certify that under penalty of perjury and0he laws of the State of California that the Information provided above is true and correct.In addition,I <br /> �o��o DQrQ pr am aware that falsification q(this inlprmptlon may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> $5,0 0 per violation per dsy as desdri e5 In Public Resources Code section 42962. <br /> d <br /> m 7:i <br /> • ,�. f <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 125130 <br />