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Oct 26 11 05: 50a Joe M :hesotti Co 209982Q464 p. 3 <br /> VY1LS.0lV"VUt�. 'FIRE <br /> rET:SERVICE.RECORD, <br /> u.s: rIRF:s'Aces TPID 1000837. 140114 <br /> 1 Sal- <br /> Wilson Way Tire Wilson Way Tire Recap #02 Connell rre <br /> #23:US.:T1KeiSales ce: <br /> #21 US"._ Sales 6530 Franklin. <br /> US TIranklin.Blvd <br /> 2600 XosBmite Blvd .: 19i5 Naf/onaFAve <br /> lfat Wilson,lNay .. 1535•MarketSt: 2211 N.'WilsonWay ya rd,:.CA94545 Saeramento,.CA95823 <br /> Stockfon,CA'9,5205.. Modesto;CA 95354 U 916-395-2245: <br /> Ctt 95205 Stockton,CA•95205' 209;571-5671 510-887-1282 <br /> ": <br /> 9�4b,5adY P O.# DATE f <br /> PHONE VEHICLE# <br /> i 7 4 <br /> LICENSE:IF <br /> , ., �:� i <br /> \`�~ STATE ZIP CODE <br /> 2CAT.lON;OF.SERVICE l- ' } it./ r G) <br /> r' <br /> DEC AL <br /> CUSTOMER TPID Ca _� c.� . . <br /> l; ursuant to Pu, <br /> certify•that,under:penalty of perjury under thedatt@s.of thit-Siste of Californla that he;lnformation.provlded above is true and wrrect In addition,I de sect redhat falsification of <br /> this Informatlon.may::result in suspension,reyQcatfon orale a °i istrative pf renewal en Itis$up:orS5,000 aste: ►R 9oI tjonn er.day s.descrbibed r�Publiic Resourcest�Code section 42962:. <br /> result.in:civil penal les.up to325,000 perday;per violation 4f. DRIVER SIGN AZ R .i" DATE <br /> RIVER NAME r;- .- <br /> X <br /> ' J. :�-•c-•r� . <br /> O <br /> HAKEDOMETER/HUB . <br /> TRUCKIFRAILER# LICENSE STATE <br /> { <br /> e `rl :DSCR/F ( at : .tee« f <br /> SERVICE CALL MOUNT I.DiSMOUNT(S)ON VEHICLE BRASS VALVE STEM(S). <br /> ALUMINUM STEM(S) <br /> FLEET INSPECTION <br /> MOUNT/DISMOUNT(S)LOOSE <br /> AIR SERVICE <br /> LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIRS) - <br /> LOOSE DISMOUNT(S) <br /> ALLIGATOR CAP(S) <br /> TIRE(S)-BALANCED . - METAL VALVE CAP(S) <br /> REPAIR MATERIAL(S) ORING(S) <br /> WHEEL SWITCH(S) RECOND1710NED WHEEL(S)'. <br /> 'FINISH,MILES: <br /> T l,. ::ia:t n 9"•" j� a"x. V4"" g ! Ymn <;r'1 d. <br /> START MILES:_ <br /> TOTAL MILES: <br /> START TIME:_—AM PM <br /> r ON SITE TIME:_—AM PM <br /> r OUT TIME:___—AM PM <br /> FINISH'. IME: =AM PM <br /> _ ',x •n y :�[+a' i�'',. r .-,'�;"'. @', �,""r�+m <br /> f"L"Ray�dtt_: *o- $f�%„o _ 4 <br /> LOAD AMOUNT ❑ OTHER <br /> GOVERNMENT Q LEA EXEMPT <br /> COMMON CARRIER/,BACK HAUL <br /> pAGRICULTURE fl �•fR <br /> ORiCK UP <br /> WHOLE TIRE COUNT WEIGHT IN POUNDS <br /> ❑ IMRORT FROM' <br /> Q DELIVERY ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> p EXPORT10 <br /> I certify that-under penalty of perjury under the laws of the State.of Callfornia:that the inforrnation:provided above Is true and correct..ivpena addition,1 <br /> ,c Para_r 'am aware that falsification:of.this-Information mayresult.In.civil:penalties up 825,000 per:--day,�:per violation-or administrative penalties up:to <br /> $5,000p�rvi6lationpgrdayas.de.ocrI bed In Public Resources Code sic6on 42962. <br /> d <br /> • ,,..., CUSTOMER SIGNATURE DATE <br /> Received Time Oct. 26.)"201111j1 7: 55AM No. 2428 <br /> CCR Ain i I Q <br /> A�� , <br />