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r - <br /> _. . .. TPI® 1000837, <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 AL Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> St, %CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 20s .-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER j I P.O.# DATE ? J <br /> I ! <br /> II 1 I PHONE VEHICLE# <br /> i 1 <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> v <br /> ` r; <br /> CUSTOMER TPID '.' <br /> I certifythat under penalty of perjury under the laws of the Stat o California that the information provided above is true and correct.Inca i I / t <br /> r I DECAL# <br /> P Y P J rY p ddition,I am aware that falsification of <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registffllion pursuah't 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 vio)5tion per day as described in Public Resources Cocke section 42962. <br /> DRIVER NAME DRIVER SIGNATVJ E %L - DATE r . <br /> CUSTOMER • • <br /> MAKE TRUCK/TRAILER# / LICENSE STATE ; ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> t� <br /> 1 <br /> Q,.. DESCRIPTION OF WORK COMPLETED_ QTY. I DESCRIPTION OF.WORK COMPLETED_- _QTY SCRIP-TION_OF_WORK_COMP-LETED- - -- — <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 I 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) I RECONDITIONED WHEEL(S) I O RING(S) <br /> Ro <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT,. �,�-'� HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT <br /> ar.i%�1 ❑OTHER <br /> � <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> O'PICK UP LOADTYPE <br /> i ❑DELI❑VERY IMPORT FROM �0 WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> F• <br /> `o Dcr4 I certify that under��}9enalty of perip�"ry under the laws of the State of California that the information provided above is true and correct.In addition,I <br /> 0o T, am aware thaVQ sification of tHis information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> °M $5,000 pervigl'tfpn per day as dgcribed in Public Resources Code section 42962. <br /> v ft <br /> 't <br /> CUSTOMER PRINT NAVIEr,•Ifo ' CUSTOMER SIGNATURE DATE <br /> 1 � <br /> FSR No. 6 18;16 <br />