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W `-.r,,, ,.,L,`2,, ,.fx `��� r m�L�"�.I• r� ..',���°ESL <br /> �� y.. b dG�tr oyb�ill6lGc� � <br /> (� -� �• TND 1000037 <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" Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Sn,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 20:. 5-0281 209-465-3262 209.466.2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER / P.O.# DATE G -' <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE _ STATE ZIP CODE <br /> CUSTOMER TPID ,; ? r `l DECAL# <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,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-7-,J (' DRIVER SIGNATURE DATE <br /> CUSTOMER •' • <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON I OFF <br /> ..`. l � j 1.-. I • --. �..... { ... ....�._..-__.- <br /> - <br /> _. <br /> DESCRIPSIONOF WORK_COMPLETED_____-_QLY_ _—_DESCRIP.TION OF.WORK-COMPLETED_----QTY. - DESCRIPTION OF--WORKCOMPLETED-- --- <br /> �I ff SERVICE CALL 'y I MOUNT/DISMOUNT(S)ON VEHICLE I BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE I 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) I RECONDITIONED WHEEL(S) O RING(S) <br /> PROuvul1117rALLED <br /> QTY /SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> !_� Wit.•/.:/ � S •/ �./ix _ _;,�?�I r f_: � :(1.°j F i.� <br /> TOTAL MILES: <br /> ` START TIME: i( I`- AM PM <br /> ON SITE TIME. AM PM <br /> car u - <br /> �v <br /> C' t_. (s l OUT TIME: AM PM <br /> FINISH TIME: i ri AM PM <br /> LOAD AMOUNT HAULER'E`,�EIGIPTION IF APPLICABLE <br /> I;: I ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE <br /> ❑COMMON CARRIER/BACK HAUL <br /> ❑PICK UP LOAD TYPE <br /> ❑ IMPORT FROM ❑WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY <br /> ❑ ExPORTTO ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <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 <br /> `or'°DQt9TrQ - 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 /> _ pY $5,000 perviolation perdayas described in Publit Resdurces Codesection 42962. <br /> r w m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. -514 <br />