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May, 17. 2010 10: 51AM WI , WAY TIRE CO, 209 242-3051 No. 8898 P, 2/2 <br /> VVILSgir,A Y i IHC Uv., FLEET SLKVIL;t RECUKU <br /> M.. TIRE SALES TPID 1000837. 132439 <br /> NRisorr Woy rite 111"Ap J002 Connell Tile #08 wifson way Tiro 021 US Tire Safes P=us Tkw Sale, 494 u5 77M Sales <br /> ay leaB MaJkef St. 2211 it wileen way 113.7 W.Fieveeth St. 2600 Yosemite Blvd. 1918 Natimial Aive. 6530 Franklin fltvd. <br /> Cv.911"A 9toekta0%Co.99209 Stoektol%Ce.95203 Tracy,Ca.55376 Afodesto,CA.95354 Hayward,G.94545 Sacramento,CA.95823 <br /> 291 <br /> 209465JR" 209466-1501 200.749€4087 20"71.J81f 510.887.1 2 916.3951245 <br /> CUSTOMS P.O. # DATE ^^^^ Q <br /> PHONE — VEHICLE`` <br /> LICENSE 1���� <br /> LOCATION OF SERVI E STAT�o ZIP CODE <br /> Li A <br /> 1 I 1 - I.� <br /> DECAL <br /> CUSTOMER TPID l_ i I j I I I I is "lick <br /> .�---�- --' # 1�, ;� <br /> I certify that under penally of perjury under the laws of the State of California that the Information provided above Is true and correct,in addition,1 am awaro that fatalflcatlon of <br /> this Intormation may result In suspenslon,revocation,or denial of renewal of the waste Tire Hauler Registration pursuant to PoWle Resources Code section 42580 and may <br /> result In civil penattles up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Cod*section 42962 <br /> DRIVER NAA DRIVER SIGNA RE DATE <br /> t X0 if <br /> MAKE TRUCK/TRAILEFI � (CENSE STATE ODOMETER/HUB <br /> SPACIAL INSTRUCTIONS ON <br /> 'QTY. DESCA1PT10N OF WORK COMPLETED O4I? SCRIPTTON OP 1#09K:'POMPLE7ED QT-1: I DESCRIPTION OF WORK COMPLETED <br /> 1 SERVICE CALL ' MOUNT/DISMOUNT($)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($) <br /> WHEEL SWITCH(S) RECONDITIONED WHEELS) O RING(S) <br /> OT' IZE7�4i <br /> IP1TON' FINISH MILES: <br /> 4' START MILES: <br /> TOTAL MILES: <br /> A START TIME: AM <br /> ON SITE TIME: AM PM <br /> OUT TIME AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUN I HAOLEA'EX£MPTION IF APPLICABLE 001 <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑OTHER <br /> --� I ❑ AGRICULTURE ❑ COMMON CASRIER/BACK HAUL <br /> PICK UP - 411 -f'�C <br /> AD TYPE <br /> 16 C3 IMPORT FROM� 4 C WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> DELIVERY <br /> O EXPORT TO 1lVOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> I Certify that under penalty of perjury under the Iaelitomia that the Information provided above is true and correct,In addition,I <br /> o�c Dafo r am aware that falsification oT this information may result in civil ponalties up to$25,000 per day,per violation or administrative penaltl*s up to <br /> $5,000 per violation per day as described In Public Resources Code section 42962. <br /> w � <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />