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Jam, WILSON WAY TIRE CO-, INC. FLEET SERVICERECORC <br /> U,S. TIRE SALES TPID 1000837. 1715,'34 <br /> a'+!is"cun ltln 7"-' IYrlson Way 1Ue R—P 002 ConneO 77m 021 US Tlro Se41-' #23 US TGa Sales 924 US Tire Solas <br /> n 1%.!5"H'.n }575 AlarA r7 Sr. 21}1 N Wilson Way 2600 Yosemlla Blvd- 1915 National Ave. 65 0 Fr 1ln <br /> Fla ard,CA 94545 Sacramento,C t8 <br /> ,,rn+•,. C4 93:0? Srcrh ren,CA 95205 Sfoehfon,CA 95205 Modosfo,CA 95754 918.395.2245 <br /> •__a-7F5-O:S7 109-1(557262 209-466-2.581 209-5715611 510-987-7282 _ <br /> Ro 0 DATE <br /> r PfiDNE VEHICLE it <br /> LICENSE 01 <br /> STATE /� D E It <br /> i <br /> CUSTOMER 7PID / r i DECAL# ' I� ,j'—�� !yi �; 3, �1 <br /> re-,fN U•at under penalty of perjury under the laws of the State of California that the InformaUon provided above Is true and correct In addMon,I am aware that falaifieatlon of <br /> f -—av—may msuil In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Codeseetlon 42,360 and may <br /> j - --s.r,r.c��i!penalties up to 525.000 per day,per violation of adminlstmtivo ponaitles up to;5,000.por violation per day ee described In Public Reaourees Code section 42982. — <br /> . K.IVE r -•^�G <br /> DRIVE S, <br /> IVEfj'SIS3 \ U E <br /> CUSTOMER VEHICLE INFORMATION <br /> TRUCKITRAILER# LICENSE STATE ODOMETER/W----N <br /> -- SPECIAL INSTRUCTIONS ON OFF _- <br /> ---- —- <br /> 147 <br /> ._• MJF. i, .� �.'� _ n•��i�j.Y . � � - <br /> / <br /> J=SCR;Il0�.0�:WORK COMPLETED QTY- OESCRIPTIQMOFWORK COMPLETED QTY." OESCRIPTIQN'DF WORK C�D <br /> -= La- MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> __ - LOOSE DISMOUNTS) ALLIGATOR CAP(S) <br /> TIRE(S)BALANCED METAL VALVE CAP(S) <br /> RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> MFG FINISH MILES: <br /> ' --- %; START MILES: <br /> TOTAL MILES: <br /> = START TIME: AM Ph1 <br /> ON SITE TIME: A1.1PM <br /> OUT TIME: Ani P61 <br /> FINISH TIME: AM PM <br /> I 11O' WAPPLICABLE <br /> ! '=OVERNMENT ❑ OTHER <br /> .JAR)CULTURE 0 L' r O �ARRIERI6ACK HAUL <br /> J""I c'. UP <br /> �,�e y w�� ---- �`~ O WHOLE TIRE COUNT L)WEIGHT IN POUNDS <br /> VOLUME CUBIC YARDS <br /> ,.-.-.�.,_-._.... .. .__._-..__ . . []WEIGHT 1N TONS <br /> hast '.• 1}a "-'507 panitSy of potjuq CAC11,lif0tnl0 that file Infil motlon provided abovo is trim,and cxrrect,in addlit+;n <br /> v ?r ,} , a. r1,:eKl�btlotl of t111M k G+ t - fi s at`rr/t,4 �u $25,000 per day, Pcr violation or adminiglrative Icnallies p <br /> Ii <br /> rury f 4n2 <br /> t <br /> ,, fla�►t <br /> C11,1676MER SIGNATURE DATE <br />