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OCT-23-2014 07:45 From: 12094654823 To:12' 348383 Page:2/2 <br /> c �'g" ,. ,1 � �r eY�I�IRS7`• ✓n E3F y'�' :.i el A'i`J�1�e`bll:^ ,R111�sll�SA'1.' til <br /> U.S. TIRE SALES TPID 1000837- 17 5 9 21 <br /> #o7 Wlison way 77re Milson way rwe Recap 002 Connell Tire al US'TIre Salts 925 U$Tam Sales "4 us 77re sates <br /> 229 N.l V80n Way 953s Market at 2211 N.101rdson Way 2600 y"emfta B", 191S Nat/onal Ave- 6690 rral"n f", <br /> Stockton,CA 96206 SYoskfo#r CA 95205 Stockton,CA 9005 Mod"to,CA 96364 nsyward,CA 94545 3Pcramentc r CA•961IN <br /> 20166-0281 209166.2507 20947140" 610�9y1282 916x395 2Ra5 <br /> COSTO P.O.# DATE <br /> r� <br /> PHONE VEH # <br /> LICENSE 0 <br /> '11~ L cr, �• .._ <br /> LOCATION OF S le n , n STATE ti ZIP CODE <br /> CUSTOMER TPID DECALS <br /> I certify first under panalty of perjury under the laws vttho slate of Callfonfw that"IrdanvtaGon provided ahoy,is true and correct.In addition.I am aware that falsifitatten of <br /> this inftrmoon may result in suspension,revocation,or denial of renewal of the Waste Mrs Hauler RegastdCon pursuant t0 Public•Ror4urces Code secWn 42960 and may <br /> raaull in rivN ppe"#mts up to$26,000 per day,per violailon of administrative per-OWS up to$5,006 per vigabon per day as described in Public Resources 0,00 stoson.42862. <br /> X NF�i SGNATC%m A OA <br /> b NER N t . lY <br /> MAKE { TRUCK/TRAILERN ICENSE STATE DID ETERMU@ <br /> SPBIAI.ItaSTAWCTIONS E ON°> OFF <br /> Iti C7r}kt' --- <br /> + 0111 <br /> f <br /> Ty ji r"oh� 'I fc p DSsPf� /ON OFws rcctiiafvl r o ern^• '.' ocseRJ rioacdFtiut> .c6 .'. . d° <br /> SERVICE CALL MOUNT I DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNTS) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT($) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL($) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> S1ZE lltfG' bCSCRiFs17a9fJ' FINISH MILES: <br /> 7;411 <br /> e' • ,�'I START MILES: <br /> TOTAL MILES: <br /> START TIME: Mi PM <br /> t ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT 'HAULGEtEXrF IF fkd IPAF''1�LE <br /> 0 GOVERNMENT 0 LEA EXEMPT 0 OTHER <br /> —-- — •—-- ❑AGRICULTURE O COMMON CAR yRI�IEfaRSAC��K++HAUL <br /> PICK UP <br /> ❑ IMPORTFROM 7 WHOLE TIRE COUNT, 0 WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑WEIGHT IN TONS <br /> 0 ptlap�TO �� ( VOLUME CUBIC YARDS <br /> I cerM1 that under p e;t of Ory under the law the State'of Califomis that the inforrnatlon provided above is true end correct.M 06010n,I <br /> dplc Pntq} am aware the l falsification of this Iriformation m esuk In civil penapies up$25,000 per day,per viol8do or administrative perwUiet up to <br /> $5.000pervioletionper day asdescribed InPublic Resources Codea n48982�y <br /> CU OMEfiT R PRINT NAME BAER SIGNATURE DATE <br /> FSR No. 17592 . <br />