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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 /> 22? Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Si In,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 20a . 5-0281 i; 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER /i! r / P.O.# DATE <br /> PHONE VEHICLE# t. <br /> LICENSE# <br /> A <br /> LOCATION OF SERVICE ,e r n / STATE ZIP CODE <br /> CUSTOMER TPID `] �.; I e'.;.� i ' 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.fn addition,I am aware that falsification of <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler j2ggistFation 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 viofation perday as described in Public Resources Code section 42962. <br /> DRIVER NAME °li! DRIVERSIGNATUREl/. f^— y DATE , o g <br /> CUSTOMER •- • <br /> MAKE TRUCKTTRAILER# LICENSE STATE ODOMETER/HUB <br /> ECIAL INSTRUCTIONS , ON OFF <br /> l'/ '1 p �fj✓%rfE ,a �1 ,r/ �} ; / `''� �f,r�'6 �r �t _ _ <br /> —QSY <br /> —� —__-_DESCRIPTION CE WORK-COMPLETED—_-Q __ -_.-DESCRIPTION OF_W_ORK_COMPLETED' <br /> �EiESCRIPTION <br /> ERVICE OF_.WORK_COMPLETED 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) I VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) I ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) I O RING(S) <br /> QTY. SIZE �ICfFG�`"� DESCRIPTION FINISH MILES: <br /> START MILES: <br /> ''t TOTAL MILES: <br /> E a I STARTTIME: AM PM <br /> ON SITE TIME: AM PM <br /> S , <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT-�r�tl� HAULER EXEMPTION IF APPLICABLE <br /> A /" I ❑GOVERNMENT ❑ LEA EXEMPT ❑OTHER <br /> --- •-- ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> 0 PICK UP LOAD TYPE <br /> ❑ IMPORT FROM ❑,WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY <br /> ❑ EXPORT TO r "(�VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty Df perjury under the laws of the State of California that the information provided above is true and correct.In addition,I <br /> D°'�DaegTr am,4ware that falsification of this information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> vy $5 OOO:perviolatioq.peritay as described in Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. G,5 y',0 <br />