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ILSCOJ64 Y TIRE CO.;,Aal r. ASF SSE r <br /> r <br /> U. 9W. 1RE SSI LE�, P D K <br /> r „ <br /> f �; <br /> Wilson Way Tire Recap 1#02 Connell Tire 405 Wilson Way Tire #`21 US Tire Sales #23 US Tire Sales k a r Ii24�US Tire Sales <br /> 1535 Market St. fC 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,Ca.95205 \Stockton,Ca.95201 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209.465-3262..: '1!094' 6&2581 <br /> ,r" 209.8354087 2Q8`5Tf-5 11 510.887.1282 916.395.2245 <br /> R rj 1 P.O. , 77, <br /> GATE t <br /> PHONE VEHICLE#111 <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID — 1� DECAL# <br /> i <br /> I 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.NAME._ DRIVER SIGNATURE DATE <br /> CUSTOMER •' • <br /> MAKE TRUL44FKAILER# LICENSE STATE ODOMETER/HUB <br /> ll- <br /> ,. SPE 1,1, S i RU€3 C1C)C�f r.. <br /> t <br /> Ov <br /> ot <br /> DEQI1PEP ,T z ;.� rQ: J <br /> SERVICE, ✓ OUNT,/DI T S t 13jZ( «B $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) 0 RING(S) <br /> PRODUCT INSTALLED <br /> A WISH <br /> u LES: <br /> F MI <br /> STAR tv(iL <br /> LES: ( } <br /> K;START TIME: `� ;AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: .Q .? AM PM <br /> LOAD AMOUNT <br /> ❑ GOVERNMENT ❑ LEA EXEMPT. ❑ OTHER <br /> ----- -- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑ PICK UP COAD TYPE, . OWN <br /> ... <br /> EI IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT 1N POUNDS <br /> ❑ DELIVERY <br /> ❑ EXPORT TO ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> I certify that under.penalty of perjuryunder the laws of the State of California that the Information provided above Is true and correct.In addition,I <br /> `oc�c Uatp rrP am aware that falsification of this Information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> a <br /> N $5,000 p'er violation per day as described in Public Resources Code section 42962. <br /> w - m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 119581 <br />