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iLI` <br /> TPID 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 N-Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> St( '7,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 20s. i=0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER rl %' P.O.#. DATE i <br /> i <br /> i1 <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMERTPIDrr ~C'�/ 14 ,L/ f 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 DRIVER SIGNATURE DATE <br /> X <br /> QUSTOMERYEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER# LICENSE f STATE ODOMETEMHUB <br /> f •�'^' ��!��< SG/ <br /> SPECIAL INSTRUCTIONS , / 'ON OFF <br /> (,v'Yfr E 6 <br /> -�f.. <br /> DESCRIPTION OF WORK COMPLETED QTY.. y! DESCRIPTION.OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> f` SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE 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 METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> l�. f ( fS'' •_� � ' .'r`%i 1 fes; I !".:if STARTTIME: r? (• AM PM <br /> y I ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: Cr _ AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> �`% ❑GOVERNMENT ❑LEA EXEMPT ;0 OTHER <br /> ——— • — ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ❑PICK UP ` i` LOAD TYPE <br /> ❑ IMPORT FROM /, <<n K ,'� I` % r' U41-IOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY Il ) Jk <br /> ± Ll EXPORTTO i A j i``�,/i ✓1 ./f `– �V, ❑VOLUME CUBIC YARDS L)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 /> o°�c D.atpTf <br /> ;,in aware that falsification of this information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> _ op $5,000 perviolation per day as described in Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DAT <br /> FSR No. 0, 0 <br />