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_ - -- - <br /> _ �. � t• =- P Fn• r -5-• 'tom r <br /> l <br /> _ . TPID 1000831` <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 AP Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Fran klin-y s <br /> St( 7,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA`95823 <br /> 204 ,-0281 i f 209-465 3262 209466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> r <br /> LICENSE# <br /> LOCATIpION-OF SERVICE-, _ � �-� STATE ZIP CODE <br /> CUSTOMER TPID S�I ! DECAL# FT�— j -- <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 j I� DRIVER SIGNATURE DATE <br /> I►_ � f e I(` X <br /> CUSTOMER •R • <br /> MAKE TRUCK/TRAILER# LICENSE STATT/E ODOMETER/HUB <br /> SPECIAL INSTRLI&IlSNS , ON OFF <br /> xx <br /> DESCRIPTION OFWORK_COMPLETED_ - QTY_ _DESCRIPTION OF WORK COMPLETED QTY _DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL kyr MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> � r <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) I RECONDITIONED WHEEL(S) O RING(S) <br /> PRODOrMiTrALLED <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME:Z ' `� �'/�A�,,PM <br /> I I ! ON SITE TIME: AM PM <br /> OUTTIME: AM PMM <br /> FINISH TIME: <// AM pmt <br /> LOAD AMOUNT <br /> HAULER EXEMPTION IF APPLICABLE <br /> --� • ��J ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> :PICK UP LOAD TYPE <br /> ❑ IMPORT FROM ❑WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> Vr_':'❑ <br /> DELIVERY ER ORT TO ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> c Darq I cert4 that under penalty of perjury under the laws of the State of Clilifo nia that the information provided above is true and correct.In addition,I <br /> I oc•� Tr am aJJvvare that falsification of this information may result in civil tSe ties up$25,O00�pea day,per violation or administrati9e penalties up to <br /> v� $5,000 perviolation per day as described in Public Resources Codes.61f n-429v62. <br /> • �• ' 1 ff l iw.rll A�"fd-/�•Y9�� !� _ ✓ pl l� .h it .� � �_ <br /> CUSTOM�R PRINT NAME ">+USTOMEk SIGNATUkE DATE <br /> r, 1. <br /> FSR NO. <br />