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vvry e <br /> Time Call Recd .630 E. Boon Ph.805928-2501 COMMERCIAL <br /> 1003035- 2 3 7 6 Mileage Time Q. <br /> Santa Mar' 3454 TPID 1003035-1 WORK ORDER <br /> Invoice# 531 E.Oak St. .805 347-4796 <br /> Start I L r ❑Santa Maria <br /> ❑Emergency CA 93454. TPID 1003035-2 <br /> Date ❑Emergency Boom 9199 EI Camino Real Ph.805 466-6224 a � j / <br /> End I ❑Atascadero <br /> ❑ScheFl <br /> ! eet Day l CA 93422 TPID 1232688-01 <br /> Sery Tech# ❑Aftar Hours 249 Montgomery Av. <br /> t 0597S&a 194E <br /> Total EI Rio/Oxnard AccouTPID <br /> t CA 93036 CUSTOMER <br /> Customer Contact Phone <br /> oC- >r.S <br /> JobLocation—Address ` State Zip Ref# PO# LOC# <br /> Directions <br /> Vehicle#- Vehicle Make License# State Odometer Vin# <br /> Trailer# Trailer Make License# State Hubometer Vin# <br /> I certify that under penalty of perjury under the laws of the State of California that the <br /> CUSTOMER TPID � _1141 <br /> � _� U Information provided above and to the left is true and correct. In.addition,I am aware that <br /> J falsification of this information may result in suspension,revocation,or denial of renewal of <br /> DECALNUMBER TRUCK LICENSE the Waste Tire Hauler Registrat(on pursuant to Public Resources Code section 42960 and <br /> CAmay result in civil penalties up to$25,000 per day,per violation or administrative penalties <br /> up to$5,00p-per day,per violation as described in Public Resources Code section 42962. <br /> Driver Name Driver'- :gnatu i } Date <br /> X <br /> Qty ;. �� ',' Size Description Mrd ;' _NV0NfJ Ply FRONT <br /> _2 LHS �l. _ k;�q <br /> sA 1�Ib ►� �� I <br /> r <br /> i <br /> L� <br /> Qty Size Flat Dismt Mount DSM switch Position/Notes Ply, ❑Customer Informed <br /> 0 0 CREDIT CARD INFORMATION <br /> ❑w/Driver Type of Card: Name as appears on card: <br /> ElVlsa Credit Card Number: <br /> ❑To Customer Yard ❑ MasterCard <br /> ❑w/Dealer/Scraping Expiration Date: Amount Charged: <br /> ❑ American Ex. <br /> ❑ <br /> wlDealer/Retread Discover <br /> I authorize SM Tire to charge my card the amount shown above:❑ <br /> DOT#on DOW off <br /> ❑ Goodyear X <br /> • • • • • • • • TYPE <br /> E] Government ElLEA Exempt ElOther: ElWhole Tire Count ElWeight in Pounds <br /> __ 77 ❑ Agriculture ❑ Common Carrier/Back haul ❑ Volume cubic Yards ❑ Weight in Tons <br /> ❑ Pick Up IMPORT FROM: EXPORTTO: <br /> ❑ Delivery � I.:! r,y, - 7 <br /> 1 certify that under penalty of perjury under the laws of the State of California that the information above is true and correct. In addition,I am aware that falsification of this information may <br /> result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per day,per viola'on as described in-Public Resources Code section 42962. <br /> o�c eQ,od CUSTOMER PRINT NAME: CUSTOMERSIGN RE: DATE: <br /> .'i I <br />