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�.; . rL <br /> TIRE C NC � <br /> . - FLEET SERVICE RECO <br /> .. w <br /> U-S, TIRE SALES <br /> �•� RD <br /> TPID 1000837• gQ � . <br /> #01 Wilson WayT/re <br /> 1535 M Way St. Recap #02 Connell Tire <br /> 221 N.lYlson Way 1535 Market St. #21 US Tire Sales #23 US Vire Sales #24 US Tire Sales <br /> Stockton,CA 95205 Stockton,CA 95205 2211 N.Wilson Way 2600 Yosemite Slvd. 1915 National Ave. 6530 Franklin Blvd. <br /> 209-465-0281 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 <br /> 209-465-3262 209-466-2581 209-571-5611 Sacramento,CA 9582. <br /> CUSTOMER 510.887- 282 916-395-2245 <br /> P.O.# DATE <br /> i <br /> r 0 �1 <br /> PHONE VEHICLE <br /> LICENSE#� <br /> LOCATION OF SERVICE <br /> 77' STATE <br /> Sl��) C b ZIP CODE <br /> CUSTOMER TPID z _O I ( _ <br /> �__l DECAL# l' <br /> 1 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,Ila—m 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$5,000 per violation per day as described In Public Resources Code section 42962. <br /> DRIVER NAME PRIV6i51GNATURE <br /> :X DATE <br /> MAKE TRUCK/TRAILER# <br /> LICENSE <br /> �-D STATE ODOMETER/HUB <br /> SPECIAL INSTRU IONS ON <br /> OFF <br /> - l <br /> QTY. D RIPTION OF WOK COMPLETED <br /> QTY. DESCRIPTION OF WORK EOMPLETED QTY. DESCRIP77ON OF WORK COMPLETED <br /> J .$-ERVICE L ...` <br /> —_ OUNT/DISMOUNT(S)ON VEHICL 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 <br /> METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> Y. ( ) <br /> QT <br /> SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> C <br /> STARTTIME: A.M PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> � �3- <br /> LOAD AMOUNT FINISH TIME: <br /> LEPM <br /> C) ( ❑GOVERNMENT HAULER EXEMPTION fFAPPLICABLE <br /> —— ❑AGRICULTURE A EXEMPT ❑OTHER <br /> Cj SCK UP Ll CARRIER/BACK HAUL <br /> ❑ IMPORT FROM��U � �, / LOAD TYPE <br /> ❑DELIVERY / �� ���c.t/? �`�/ <br /> Cf EXPORT TO-" Cl KNHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> �• t I r �� / �]VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under Penalty <br /> Ury <br /> sot'` DQrQ�r am aware that falsification oof this nfodmationGr the <br /> imay aws result in civil peState of lnaitels up$25,000 per day,per violation Information provided vor administrative penaltlese is true arid correct.In iuipnto <br /> $5,000 perviolation perdayas described In Public Resources Code section 42962. <br /> w o <br /> �$ <br /> CUSTOMER PRINT NAME _ CUSTOMER SIGNATURE <br /> FSR NO. 1 8 0 9 3•:k - DATE <br /> - - �V =- - <br />