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C:.. .. FLS <br /> r <br /> US, SALES <br /> r TIDE �TPID�O.00�3T` � <br /> #01 W!/son Way Tire Wilson Way Tire Reca 4 �� t <br /> 221 N.Irlson Way 1535 Market St P 221 Connell Are #21 US The Solas #91 N The al Ave. #24 US FTire <br /> ranklin <br /> 2211 N Wilson Way 2600 Yosemite Blvd. 1915 National Av6530 Franklin Blvd' <br /> Stockton,CA 9#1105- Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823'` ay <br /> 209.465-0281 209-465-3262 209-466.2561 209-571-5611 510-887-128? 916-395-2245 <br /> CUSTOMER -� DATE <br /> (((/ PHONE VEHICLE# <br /> LICENSE# <br /> r <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID — DECAL# �� fi <br /> l t1 ��.Z'� . < LP 1 <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,revocatlon,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 DRIVERSIGNATURE { DATE <br /> CUSTOMER VEHICLE INFIDIRMATION J <br /> MAKE V TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> eons: <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. f DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLJE BRASS VALVE STEMS) <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 /> QTY SIZE MFG ' DESCRIPTION FINISH MILES: <br /> .je <br /> START MILES: <br /> All <br /> s- TOTAL MILES: <br /> > � i <br /> ..._ <br /> START TIME � A PM.. <br /> ON SITE TIME:ter`rr^r�Z-' (51 Pm <br /> OUT TIME:" AM PM <br /> - FINISH TIME: ZZ AM 01M <br /> LOAD AMOUNT HAULER EXEMPTIOFI'IE'APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> - ---T -- ❑AGRICULTURE <br /> ❑COMMON CARRIER/BACK HAUL <br /> ❑PICK UP LOAD TYPE <br /> ❑ IMPORT FROM - <br /> ❑ DELIVERY J3 WHOLE TIRE COUNT ❑WEIGHT IN POUNDS ' <br /> ❑ EXPORTTO VOLUME CUBIC YARDS ❑WEIGHT N TONS <br /> q i <br /> un�c pato ` I certify that under penalty of perjury under the laws of the State of California that the Information provided above Is true anSL&irect.in addition,l <br /> am aware that falsification of this Information may result In civil penalties up$25,000 per day,per violation or administreflfie penalties tip to <br /> 5,000 per y <br /> � p pp as described lnPublic Resources Code section 42962. <br /> A <br /> m r r <br /> w r _ <br /> �.�_A L i_ A � 4 n . l f-'�j 7�'___ �� +Si �ilf•Eri} t% ;.1 �.''!- i � <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. .7%`51492 <br /> .___ .. - _ _•--•.:mow-..._ _. _'.`-=_ate.-_ '. 1. �. _ - -.--4-�'=�.♦ <br />