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From:CENTRAL CALIF TRACTION 2094666927 06/0'!2013 07:47 #646 P.003/003 <br /> 1-209-242-3051 11:00:24 06-04-2013 1 /1 <br /> tt YY/LaJV/1/ YYf{T /IITC tiV.r I/Vlr. rLCCI OCKVI"Kt%oUKU VAI%t- <br /> U.S. TIRE SALES TPID 100083!:'15 0 0 6 0 <br /> 1 Wilson WayTlre tiylfson Way 7Jre Ree 902 Connell Tire r 021 US Tiro Sales 423 US Tire Sales #24 US T#re Sales <br /> 1 N.Wilson Way 1535 Market St. 2211 N.Wilson Way._ 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> ockfon,CA 95205 Stockton,CA 95205 Stockton,CA 95205 odestq;:CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 9-465.0281 209-4653262 209-466-2581 9.571.5611 510.887.1282 916.395-2245 <br /> ISTOMER- _ DATE <br /> e G -1 <br /> PHONE VEHICLE# <br /> LICENSE 9' <br /> / <br /> 8' N� <br /> CATION OF SERVICE STATE LP CODE <br /> 1 .• I 1_.._I I_ _ <br /> CUSTOMER TPIO 1 J /1 <br /> I i o AL fl �— d <br /> I certify that underpin ally of psdury under the laws o1 the State of California Ihat the Information provided above 19 e d correct.In addition,I am aware that falsification of o.. <br /> this Information may result In suspension,revocation,or denial of renewal of the Waste Tire Ha aglstration p su t to Public Resources Code'saatlon 42960 and may <br /> result In civil peneltlea up to$25,006 per day,per violation of administrative penalties up to S 0 r violation d as described In Public Resources Co sectio 42962' <br /> IVER NAM DRIVER SI TU DATE <br /> �. X <br /> • •� • <br /> KE' r RUCKITRAILER�W LICENSE STATE ODOMETER/HUB <br /> Y:. cIk INSTRUCT-lows <br /> ,. f OFF <br /> ISI ,�; :.:- ---- -- ----•----------- <br /> COAftRL3E33'a' <br /> - . ,'pYQRK'C. •QTY. DESCAIP710N6FWORK'COMPLE7ED • <br /> : <br /> •SERVICE.CALL <br /> MOUNTI' DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> ""FLEET INSPECTION MOUNT/.DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MQUNT(S) VALVE STEM REBUILDS) <br /> FLAT REPAIRS) LOOSE DISMOUNTS) M ALLIGATOR CAP(S) <br /> 77 <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED `' METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) R1tC> t�tl `_t7NED WHEEL(S) O RINGS) <br /> `' '.__..... sfzE _ ., ...MFC9 '.'..41. 4 *44=11 ..` — FINISH MILES: <br /> r JD L` START MILES: <br /> TOTAL MILES: <br /> 3T5 3ra STARTTIME: b. AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: AM PM <br /> IAD AMOUNT HAULER-F-)(EMP,TIO►J I,�APPLICABLE <br /> L]GOVERNMENT L]-LEA EXEMPT <br /> —— (D AGRICULTURE L)COMMON CARRIER/BACK HAUL <br /> UPCEh1 -- L AD TYPE <br /> Q IMPORT FROM_ <br /> W ELIVERY ^ HOLE TIRE COUNT Q WEIGHT IN POUNDS <br /> ❑ EXPORT TO 11-Dy�)� ❑VOLUME CUBIC YARDS L]WEIGHT IN TONS <br /> \c pard I certify that under penally of par(ury under the laws of the Stale of Callfomla that the Information provided above Is true andcorrect.In addition,I <br /> art aware that falsincallon of this Informal! n may result In'civil penalties up$25,000 per day,per violation or administrative penaliles up to <br /> ;5,000 per violatlan perday as described in Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> SR No. 15 n n Fi Okill? PLEASECSOE LOnN AT Ta <br /> 7y <br /> JIM. Am <br /> Received TITJ� , . 7. 201 9: 01AV1 No. 067; VW <br /> V <br />