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Sr lay TIRE CO., INC. SLEET SERVICE RECORD <br /> TIRE SALES <br /> TPID 1000837. 17 4 8 9 <br /> #01 Wilson Way Tire Wlison Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 211 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 /> 209-465-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-3952245 <br /> CUffMER, t % P.O.# �DATE <br /> Ijac r �Wdglr- LO <br /> PHONE HICLE# <br /> jol <br /> LICENSE# <br /> G51 125PMA <br /> LOCATION OF SE ICE STATE ZIP CODE <br /> � I <br /> CUSTOMER TPID DECAL# /� <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 adminlstrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER N DRIVER SIGN RE DATE <br /> X <br /> CUSTOMER •' • <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS r ON OFF <br /> \\ <br /> TY.1 I SCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SE VICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MZTTMT7 DIS OURT(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 /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCTt <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> O START MILES: <br /> TOTAL MILES: itlu <br /> START TIME: AM M <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME142�1_ _AMPM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> • ❑AGRICULTURE ❑COMMON CARRIERIBACK HAUL <br /> PICK UP ]ETYPE <br /> LlIMPORT FROM OLE TIRE COUNT <br /> ELIVERY ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO LUME CUBICYARDS ❑WEIGHT IN TONS <br /> `c parQ I certify that under penalty of perjury under the law o fie State of California that the information provided above is true and correct.In addition,I <br /> moo Tro am aware that falsification of this information ma esult in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> o $5,000 per violation perday as described in Public Resources Code section 42962. <br /> � m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 17489.0 PLEASE CIRCLE STORE LOCATION AT TOP <br />