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; FFT SFRVICF RECORD <br />TPID 1000837• <br />#23 US Tire Sales <br />14 il_ 0111 L-, <br />v Tiny' rn <br />imr <br />i ;7� ;J -F> <br />, <br />U.S. TIRE SALES <br />510-887-1282 <br />#01 Wilson Way Tire <br />Wilson Way Tire Recap <br />#02 Connell Tire <br />#21 US Tire Sales <br />221 N. Wilson Way <br />1535 Market St. <br />2211 N. Wilson Way <br />2600 Yosemite Blvd. <br />Stockton, CA 95205 <br />Stockton, CA 95205 <br />Stockton, CA 95205 <br />Modesto, CA 95354 <br />qno-ear-ma1 <br />209-465-3262 <br />209-466-2581 <br />209-571-5611 <br />; FFT SFRVICF RECORD <br />TPID 1000837• <br />#23 US Tire Sales <br />#24 US Tire Sales <br />1915 National Ave. <br />6530 Franklin Blvd. <br />Hayward, CA 94545 <br />Sacramento, CA 95823 <br />510-887-1282 <br />916-395-2245 <br />CUSTOMER <br />P.O. # <br />DATE <br />_ / yPHONE <br />d(4- <br />VEHICLE # <br />/22 <br />LICENSE#6 <br />LOCATION OF SERVICE <br />STATE ZIP CODE <br />CUSTOMER TPID I JI�� i151 — (�� DECAL #— �% F <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 of administrative penalties up to $5,000 per violation per day as described in Public Resources Code section 42962. <br />DRIVER NAMEDRIVER <br />CUSTOMERO <br />MAKE TRUCK/TRAILER # <br />SIGNATURE DATE } 2 <br />X <br />• <br />7 ---LICENSE STATE ODOMETER/HUB <br />i <br />SPECIAL INSTRUCTIONS <br />ON ------ --- <br />-T- <br />--- OFF-- ---- -- <br />QTY. <br />DESCRIPTION OF WORK COMPLETED <br />QTY. <br />DESCRIPTION OF WORK COMPLETED <br />QTY. <br />DESCRIPTION OF WORK COMPLETED <br />SERVICE CALL <br />MOUNT / DISMOUNT(S) ON VEHICLE <br />BRASS VALVE STEM(S) <br />FLEET INSPECTION <br />MOUNT / DISMOUNT(S) LOOSE <br />ALUMINUM STEM(S) <br />AIR SERVICE <br />LOOSE MOUNT(S) <br />VALVE STEM REBUILD(S) <br />FLAT REPAIR(S) <br />LOOSE DISMOUNT(S) <br />ALLIGATOR CAPS) <br />REPAIR MATERIAL(S) <br />TIRE(S) BALANCED <br />METAL VALVE CAP(S) <br />WHEEL SWITCH(S) <br />RECONDITIONED WHEEL(S) <br />O RING(S) <br />QTY. <br />SIZE <br />• ,a <br />vanIffl"by <br />MFG <br />DESCRIPTION <br />FINISH MILES: <br />START MILES: <br />TOTAL MILES: <br />f <br />START TIME: AM PM <br />ON SITE TIME: AM PM <br />OUT TIME: AM PM <br />FINISH TIME: AM PM <br />t—ii1:1- <br />l <br />LLOADAMOUNT <br />— — — — — • — — <br />❑ GOVERNMENT <br />❑ AGRICULTURE <br />HAULER EXEMPTION IF APPLICABLE-- <br />❑ LEA EXEMPT ❑ OTHER <br />❑ COMMON CARRIER/BACK HAUL <br />(] PICK UP <br />❑ IMPORT FROM _._ _. _ __ -- - - <br />❑ DELIVERY❑VOLUME <br />,--i FXPCIRT T(� <br />- - -- - <br />LOAD TYPE <br />J WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br />CUBIC YARDS FA WEIGHT IN TONS <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 <br />`orc CaroT+G am aware that falsification of this information may result in civil penalties up $25,000 per day, per violation or administrative penalties up ;to <br />w <br />$5, 000 PPrviolation perday as described in Public Resources Code section 42962. <br />_ m <br />w _ CUSTOM /R PY21 TNAME r' � <br />CUSTOMER SIGNATURE a` r' (r /( DATE <br />FSR Nn <br />