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Y TIRE CO., INC. FLEET SERVICE RECORD <br /> �. TIRE SALES _ TPID 1000837. -17 4 8 5 3 <br /> tut Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N. Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> t09-465.0281 209-465-3262 209.466-2581 209-571-5611 510.8874282 916-395-2245 <br /> 'USTOMER P.O.# DATE <br /> Vn <br /> PHONE VEHICLE# ` <br /> LICENSE# <br /> .00ATJON OF S ICE STAT ZIP CODE <br /> 0-1 <br /> �. .. _..._. �-I DECAL# l L '! <br /> CUSTOMER TPID <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 /> )RIVER DRIVER SIGNAT DATE <br /> X <br /> CUSTOMER • <br /> RAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> ------------- <br /> 4 105;71LA <br /> . <br /> TY. DtIkRIPTIONOFIMORK COMPLETED - TY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED. <br /> SE ICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE.STEM(S) <br /> FLEET INSPECTION MOUNT/D SMOUNT(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 <br /> TY. SIZE MFG DESCRIPTION FINISH MILES: <br /> Le <br /> START MILES: <br /> TOTAL MILES: <br /> + START TIME: ' AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME:y ,lxJ APM <br /> LOAD AMOUN HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> —— •— ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UPLOAD TYPE <br /> C) IMPORT FROM WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ELIVERY <br /> ❑ EXPORTTO ' VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty of perjury under the I s of the State of California that the information provided above is true and correct.In addition,I <br /> �o0 DCtp Jr am aware that falsification of this information y result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> MAMA $5,000 per violation per day as described In Public Resouroes Code section 42962. <br /> w <br /> • • 2, 6 <br /> ¢� <br /> CUSTOMER PRINT NAME CUSTOMER SIGNA URE DATE <br /> FSRNo_ 1 T A A S R MR r-Ar r- n1r1^1 r- r+rfNr-)r- i r,r1Arie-%ni AT Terri <br />