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VV/U+r <br /> 1003035 Time Call RecBo <br /> d Mileage Time 630 E. on Ph.805 928-2501 COMMERCIAL <br /> 23768 Santa Mar' 3454 TPID 1003035-1 WORK ORDER <br /> Invoice# 531 E.Oak St. h.805 347-4796 <br /> ❑Emergency Start ❑Santa Maria CA 93454 TPID 1003035-2 <br /> Date ❑Emergency,800m 9199 EI Camino Real <br /> End ❑Ata•oadero Ph.805 466-6224 0 O <br /> 0 Sched:Fleet Day CA s3a22 TPID 1232688-01 •^' <br /> Sery Tech# ❑AtteF Hours 249 Montgomery Av. .S4W/949 <br /> ❑Nat'I Account Total ❑EI Rio/Oxnard <br /> Ph.805 642-0174 <br /> CA 93036 TPID 1197378-01 CUSTOMER <br /> Customer Contact Phone <br /> Job Location-Address State Zip <br /> Ref# PO# LOC <br /> Directions <br /> Vehicle# Vehicle Make License# State Odometer Vin# <br /> Trailer# Trailer Make License# State Hubometer <br /> I certify that under penalty of perjury under the laws of the State of California that the <br /> CUSTOMER TPID ' information provided above and to the left is true and correct. In addition,I am aware that <br /> _L 3 lLl;b <br /> si_r:�e_NUMBER _ TRUCK LICENSE- - ID] falsification of this information may result in suspension,revocation,or denial of renewal of <br /> the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and <br /> �} I`1 may result in civil penalties up to$25,000 per day,per violation or administrative penalties <br /> . ..._-ICA up to$5,000 per day,per violation as described in Public Resources Code section 42962. <br /> giver Name Driver's Signature Date <br /> X <br /> y�y,pp� <br /> Qty `•'.`;.#�,. ST�:.`I 'e `.:;r" ?,... ....., ...'''481 ...... �•$.Rtl .v. V Ply FRONT <br /> I <br /> r. <br /> — -AiJ t> F1 F E [I <br /> P [1] <br /> Qty Size Flat Dismt Mount D&M switch Position/Notes Ply ❑Customer Informed <br /> CREDIT CARD INFORMATION <br /> Type of Card: Name as appears on card: <br /> ❑w/Driver El Visa <br /> Credit Card Number. <br /> ❑To Customer Yard <br /> ❑ Master Card <br /> Expiration Date: - Amount Charged: <br /> ❑wlDealer/Scraping ❑ American Ex. <br /> I authorize SM Tire to charge my card the amount shown above: <br /> ❑wlDealer/Retread ❑ Discover <br /> DOT#on DOT#off <br /> ❑ Goodyear X <br /> • • AMOUNT 1HAULER EXEMPTION • .D TYPE <br /> ❑ Government ❑ LEA Exempt ❑ Other: ❑wlNhole Tire Count ❑ Weight in Pounds <br /> • ❑ Agriculture ❑ Common Carrier/Back haul - ElVolume cubic Yards ❑ Weight in Tons <br /> Pick Up IMPORT FROM: EXPORT TO: <br /> ❑ Delivery <br /> I 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 violation as described in Public Resources Code section 42962. <br /> c9"0 ' CUSTOMER PRINT NAME: CUSTOMER SIGNATURE: I �- � '` DATE: <br /> L: i� <br />