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t <br /> WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837- 1-71392 <br /> i <br /> #23 US Tiro Sales #24 US Tire Sales <br /> y't H il:.v+Way Trn• lvifsnn Way Tim Recap #02 Connoll Tiro 921 US Tlro Sales 1915 NationoiAve. 6530 Franklin Bfv <br /> •+.q Isil$—lyse 1535 Markef Sf 2211 N.Wilson Wny 2600 Yosom7fo Blvd. Ha ard,CA 94545 Sacramento,CA iB <br /> CA 95W-1 SrocAtom CA 95105 St—AMn,CA 95205 Modesto,CA 95354 510-BB7-1282 916-395-2245 <br /> t.c.at c2a.yy-- '- 2p9-Id5--7262 209-466-2581 209-571-5611 — <br /> DATE <br /> J o <br /> P.O. 1 p <br /> i <br /> Jr <br /> ------ --t--- -..-----PHONE ------ VEHICLE# / 1 f <br /> I _ <br /> - -- ----------------------- LICENSE#r <br /> STATE ZIP jC <br /> CUSTOMER TPID - / — i; I DECAL# <br /> v-•`:tUt ender penalty of perjury under the laws of the Stale of California that the Intormatlon provided above Is true and correct In addition,I am aware that falsification of <br /> on may msult In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> In�.,.1 pena"ties up to$25,000 per day,per violation of adminlstrative penalties up to$5,000 p"lolation per d as described In Public Resources Code section 42962. — <br /> =q DRIVER IG TU DA <br /> J J _ I <br /> X - y r I S <br /> TFUCI TRAILER k rLICENSE STATE ODOMETERIHU c <br /> SPECIAL INSTRUCTIONS , ON t:' c...OFF <br /> - <br /> ` i ) — <br /> o _ <br /> ?;,F rC`!C.=WDRK COMPLETED QTY. DESCRIPTIONOF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> -;L- 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 /> =r.=. LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> TIRE(S)BALANCED METAL VALVE CAP(S) <br /> RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT INSTALLED <br /> _ ZE MFG '. "71-7W'!;' }�b`ERIP770fl1 FINISH MILES: <br /> i START MILES: <br /> S <br /> — -- 1 -2 <br /> I ►" L a/ U 1- K TOTAL MILES: <br /> t. F. <br /> START TIME: ANA PM <br /> -------------------.----.--_-- — ON SITE TIME•. AM PAI <br /> OUT TIME: AN ?M <br /> FINISH TIME:_ AU Ph1 <br /> 3� �1 7 IFAPPLICABLE <br /> ,. <br /> ' ..J <br /> GOVERNMENT ---_____-- <br /> Q LEA EXEMPT -------- <br /> s OTHER <br /> LjAGRICULTURE COMMON CARRIER/BACK HAUL <br /> PE <br /> -- .-- riv <br /> HOLE TIRE COUNT ]WEIGHT IN POUNDS <br /> LUME CUBIC YARDS i•_]WEIGHT IN TONS <br /> i v:at„r14rpvnlWja/ IA111Wt1lf11 !plf B►t�i q}CNKorMM Ute1 Lh•Information ptov;dBd ahovc'w iron and eorTecl.tit addition,I <br /> tt..f3{i1• cMl Aw <br /> P+tt t�w# up S26,11im per day, per vlul,itien or a.inunfalrative panaltles up to <br /> 1' t S ,:ytr nn,7 r r IAI4�it�M1�V Cod*11901I0I1 42962. <br /> t <br /> -',"Rr rr P c'tP r t.AME CUBTOkIEA SIGNATURE F' '/'�ti,4 l� <br /> f DATE <br />