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f Lsury 4Dr 'rcc ., nv �1TI�F;EC7*..-. <br /> U.S, TIRE SALESvvTPID 1000837. 181480 <br /> Wilson Way Tire Recap #02 Connell Tire #27 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> ay 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Aye. 6530 Franklin Blvd. <br /> 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 181 209-465-3262 209-466-2581 209-571.5611 510-887-1282 , 916.395-2245 <br /> MER � P.O.# DATE <br /> PHONE VEHICLE# ^ <br /> LICENSE#- <br /> - STATE ZIP CODE <br /> LOCATION OF S I tRVICE <br /> r--T.—._I` r DECAL# <br /> " CUSTOMER TPID I, i3 2 l�l I(�`°� I— ` <br /> R I_ _-1,.s <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,F am aware that falslficatlon of <br /> this(ntonnation may result In suspension,revocation,or denial of renewal of the Waste Ti r Istration pursuant to Public Resources Code section 42960 and may <br /> re utt lit civil Itles up to$25,00 ar day,per violation of administrative penalties up t 55,000 per olation per day as described In Public Resources Code section 42962. <br /> PRIVERaJPI, DRIVER SI A DATE <br /> • XCUSTOMER VEHICLE INFORMiKNON <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> s S-7r�L� ce, <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> Q7Y DaSCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETEp e <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 /> LREPAIR <br /> REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> ERIAL(S) TIRES)BALANCED METAL VALVE CAP(S) <br /> CH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> e a FINISH MILES: <br /> QTY. SIZE MFG DESCRIPTION -ry <br /> —z/? / t START MILES 7 <br /> �7 CSJ' TOTAL MILES:-;;90 <br /> START TIME: AM PM <br /> ON SITETIME:Cqi.L.J'> __—AM6 <br /> OUT TIME: '� AM PM <br /> t.• FINISH TIME: �r� AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE ' <br /> '1 ❑GOVERNMENT ❑LEA EXEMPT OTHER <br /> — --�-- ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ICK UP LOAD TYPE <br /> ❑ IMPORT FROM — ❑WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> DELIVERY LJ VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ❑ EXPORT TO t. ,�'7 C <br /> I certify that under penalty of perjury under the laws of the State a Ifomia that the Information provided above Is true and correct.In addition,-4�', <br /> �c Dole, am aware that falsification of this Information may result In p allies up$25,000 per day,per violation or administrative penalties up to <br /> ° $5U1W�'t ,000 per violation per day a described In Public Resources dose on42962 <br /> 0 <br /> m _ <br /> CUSTOMER PRINT NAME CUS T ME ATURE DATE <br /> FSR No. 181480 PLEASE CIRCLE STORE LOCATION AT TO <br /> . >i: ) ?i- I n( ATInt\; .6 - mo <br />