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22-OCT-2014 14:04 From:. 2095551212 To:97 '83 Pa9e:4/5 <br /> MTWto re 4:: <br /> FLEET SERVICE RECORD 01/07//y <br /> �° ACES „•�. <br /> TPID 1000837. 17 5 2 2 4 <br /> y Tree Wi'laon Way rke ReW #a caned►Tole #24 921 US Tree sa/es ATJ US Tyra 3'165 t13 Ten Saha <br /> 28!N,*Milson Nyy 16351ffarSt 2211 N.*Won Wjy 2W0 Yoserafte l3kd 1916 NaBnnalAvo. 65M Franldat Blvd <br /> 5toc#Yon,GA 95205 3rockMn,CQ A 95y05 Stockton,CA 952W Af0dRsto,r.4 98354 thyward,CA 94SU Sscra Mento,dA 46823 <br /> 20940&0281 208165.9267 209.168 2591 209. 11.661! 510 487-1292 91B 383.2245 <br /> CUSTOMER <br /> DATE a� p <br /> EHICLE 4 �Q <br /> '' LICENSE 9 �j t1 <br /> LOCATION OF SERVICE T �T <br /> STATE ZIP CODE <br /> CUSTOMER TWO - L� '� DECAL# �►Y� 0 © 1 <br /> IcarlUythatundeepene of IIEZ, - <br /> penalty itorJury under Me laws of flea State of rolfivmla ihaRlhe Information provkw above 14 true end eoneet.In addition I am aware that fatsbiyycn of <br /> this trMormatiaa mey result in suspension,revocation,or denial of renewal otthe Vyasts Tiro Mauler Wrptsb"on pursuant to Public RG9euroea COdo section g2y6if and mat <br /> result In civil panatfies up to ti25,000 per day ppr violation of administrative pen up to$5,400 pqr vieledon per day ae deft lbed in Public Reaourees Code sedgn 429". <br /> ME <br /> rFVePIGNATUREMAKER 6AT1: <br /> TRVCKITRAILER# LICENSE STATE CDOMEiEW1-tU13 <br /> _ .YY:�^- .,,,.iy�. _ V• <br /> bill <br /> QIV3,1:•%J�' �,.�•,,,.. .RiCX .i-. r - _ <br /> ` ;,'1?}..[_ •.f; Li.•�- M .��.Nr k'�. `tlti..l. - M. 1N••-' r�1.Ze.. <br /> � '��t:-'�i. 'IIF.' J` U j �x'�' '�F,�a`�d�n •�,... ------"'----' <br /> OUNT/DISMOUNT LE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)(.DOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD($) <br /> FLAT REPAIRS) LOOSE DISMOUNTS) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRES)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> •�xgas <br /> °',��,+�3E5'�'fP770.. :v.-�_. -i: '•-$:T• ?,� FINISH MILES:� <br /> r START MILES: <br /> TOTAL MILES: <br /> START TIME, <br /> ON SITE TIME: <br /> OUT TIME: AM PM <br /> LOAD AMOUNT FINISH TIME: pM <br /> —— (�l•` !]GOVERNMENT Q LEA EXEMPT : Q OTHER <br /> AGRICULTURE Q COMMON CARRIER/BACK HAUL <br /> L�MK UP <br /> d IMPORT FROM '34 at III, Jed <br /> •: > ','iq'. <br /> Q DELIVERY n ( HOLE TIRE COUNT Q WEIGHT IN POUNDS <br /> v-:w�ORTTO •Q VOLUME CUBIC YARbS Q WEIGHT IN TONS <br /> I Certify Ilia!ultdlr barely o!pery'ury u <br /> 4a Relq r the iaws orthe State of"irwia that the Information Provided above ht Ma and cofrept.In addltion,t <br /> o 41 *;"aware th t fools cation•of this hrfaffnAgn may result In civil penalties u $25.000 per day,pot violation or administrative 0jnaldes up to <br /> g par dayst described in Publlc Resources Cade,^.octhur 42092. <br /> Ct15TOMEit PRINT ijAME CUSTOMI X 61G11ATURE DATE <br /> FS N0. 175224 PLEASE CIRCLE ST <br /> '� •�. x_ .:��.��:,,�.:�:�-+�::G...�: .:,.x. QRE LOCATION A7 TCP <br />