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LSO`' ier TIRE CO:, INC. ET SERVICE RECORD <br /> 1.45! <br /> TIRE SALESTPID 1000837. 17 6 5 0 9 <br /> Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 USwsTjrg Sales #24 US Tire Sales <br /> 1535 Market St. 2211 A Wilson Way 2600 Yosemite Blvd. 1915 NaggoalAve. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Haywaid,'CA 94545 Sacramento,CA 95823 <br /> IZ81 209-465-3262 209-466-2581 209-571-5611 510-887,1282... 916-395-2245 <br /> M R P.O.# DATE .'G <br /> A�z -.2 <br /> PHONE VEHICLE# <br /> LICENSE# <br /> "OCA T OF SE VICE STATE ZIP CODE <br /> ------- <br /> CUSTOMER d FlDenal of perjury under the s of the� ECAL# i������ <br /> I tate o�a <br /> certify penalty j ry Californialifornia that the information provided above is true and correct.In ad ition,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 /> 7RIVER NA DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •' • <br /> MAKE RUCK/TaRAILER# LICENSE STATE ODOMETER/HUB <br /> 34// <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION,OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(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) O RING(S) <br /> PRODUCT INSTALLED <br /> QTY. SIZE 'MFG DESCRIPTION FINISH MILES: <br /> v' ® START MILES: <br /> III TOTAL MILES: <br /> STARTTIM AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IFAPPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT OTHER <br /> •—— ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP �° LOAD TYPE <br /> LDIMPORT FRO HOLE TIRE COUNT LJ WEIGHT IN POUNDS,,,.. P,.. <br /> DELIVERY <br /> ❑ ExPORTTo ❑VOLUME CUBIC-YARDS ❑WEIGHT IN TONS <br /> —71 <br /> I certify that under enalty of perjury under the laws of the State of California that the information provided above Is true and correct.In addition,I <br /> octic DetoTf am aware that faisifi6tion of this information may result in civil penalties up$25,000 per day,per violation or administrative penalties up to <br /> oy 00 perviolatlon`p`er�asdescribedinPublicResourcesCodesection42962. <br /> CUyOIhER PRINT NAME CUSTOMER NATURE DATE <br /> FSR No. 1765 9 <br /> -"-OLEASE CIRCLE STORE LOCATION AT TWI" <br />