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U.S. TIRE SALES TPID 1000837- <br /> #01 <br /> 000837 ,Q '' •`, <br /> !' f;w , <br /> #01 Wilson Way Tire <br /> Wilson Way Tire Recap #02 Connell Tire #21,US Tire Sales #23 US 77r6 Sales #24 US lrlre Sates a <br /> 221 N.Wilson Way 1535 Market St 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramen eA 582$ , <br /> 209-465-0281 209-465-3262 209-466-2581 209,571-5611 510-887-1212 918 3g5Z�S <br /> CUSTOMER P.O.#' QATE ; <br /> i PHONE VEHICLE#) ' <br /> LICENSE# <br /> LOCATION OF SERVICE STATE f ZIIb CODE) <br /> CUSTOMER TPID �) "� �' <br /> i(��' jJ l �—�� DECAL# IJ la <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 suspensio0,revocation,or dental 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 D I ER SIGNATURE DATE <br /> =ToMER VEHICLE INFORMATION <br /> MAP E TRUCK/TRAILER# LICENSE! STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> QTY. DESq/gieT.LQaOF 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 OLIN T/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) 0 RING(S) <br /> INSTALLEDPRODUCT <br /> QQTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> \✓ �j � � r ;�l* (`✓C ! fJj / r')�f/� START MILES: <br /> 7� TOTAL MILES: /C7 <br /> STARTTIME; `3 AM <br /> ON SITE TIME: AM PM <br /> OUTTIME: hh AM PM <br /> FINISH TIME: lJ AN2� <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> �• �-' ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> —` ❑AGRICULTURE _ <br /> ❑COMMON CARRIER/BACK HAUL <br /> 0•PICK UPLOAD TYPE <br /> LI IMPORTFROM <br /> ❑DELIVERY - WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> O EXPORTTO `�J �( �r,_,f �� �,,� t_r; / S - ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> pQta 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 <br /> yoo� Two am aware that falsification of this Information may result in civil penalties up$25,000 per day,per violation or administrative penalties up to <br /> �, M S5 OOpervi� onperdayasdescribedlnPublic ources Code section 42962. <br /> 9(f4TCMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 181099 E5 , <br /> K <br />