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1-209-242-3051 14:05:12 07-11-2013 3/33 <br /> WILSON k& TIRE CO., INC. ,'LEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837 16 5 4 0 1 <br /> 101 Wilson Way T7re Wilson Way Tire Recap 902 Conned T/r�- . #21 US T7re Safes #23 US Tire Sales #24 US Tire Sales <br /> '21 N.Wilson Way 1535 Market SL 2211 N.Wi/sdn Way 2600 Yosemite Blvd,' 1915 National Ave., 6.530 Franklin Blvd. <br /> tockton,CA 95205 Stockton,CA 95205 Stockton,CA.95205 Modesto,CA 95354- Hayward,CA 94545 Sacramento,CA 95823 <br /> 09.465.0281 209465.3262 209-466-2581 209-571-5611 510-881-1282.1.E 916-395-2245 <br /> USTOME <br /> P.O.# DATE / <br /> PHONE VEHICLE# Q <br /> LICENS7za�? <br /> DCAT OF AVICE STATE �,�Zj9tODE <br /> G / LCL1. <br /> CUSTOMER TPIDDECAL# <br /> jj f� <br /> �_l_..- �9 Pqi�. _ C�UI certify that under ponalty of porjury under tho laws the State of California that the Information provided above Is true and correct In yl— <br /> ofltion,I am aware that faisl(lcatlon of <br /> this Information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code sectlon 42960 and may <br /> penalties result In civil up to$25,000 per day,per violation of administrative penailles up to$5,000 per violation per day as described In Public Resources Code section 42962. <br /> RIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •- • <br /> AKE -• + TRUCK/TRAILER# LICENSE STATE ODOMETERIHUB <br /> 1 <br /> al?EEIAF'1t8IRU�`'t`Cb , ON OFF0-k Ygy <br /> Lb <br /> O�, <br /> _ - - <br /> QTY VL- <br /> O�W6Rk'COWLMI�6 QTY.- DESCRIPTION OF WORK COMPLETED QT-Y DESCRIPTION,OF WONK C6A;fPLETaO <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSf-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 /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> '•r r <br /> 47Y ;. _._..- FINISH MILES <br /> DESCRIpllt3 <br /> START MILES: <br /> TOTAL MILES: <br /> W011l� • START TIME: M <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: �� A PM <br /> .oAD A HAULER EXEMPTION IF APPLICABLE <br /> O ❑GOVERNMENT ❑LEA EXEMPT ER <br /> —— AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UPLOAD PE <br /> �DELIVERY <br /> C) IMPORT FROM //f ;7 L WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> EJ EXPORT TO17 (� Al•fp ✓'� ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> polo I certify that under penalty of perjury under the laws of the St of California that the nforrn tion provided above Is true and correct.In addition,I <br /> am award that falsification of this information may res 1 n cl II Wallies up$25 00 pe da , per vlolatlon or administrative penalties up to <br /> Y $5,000 per violation per day as described In Public Rasa cesCod tion4296 . <br /> CUSTOMER PRINT NAME C TOMER SIGNATURE ATE <br /> �SReceived Time�Ju1 11, 2013 ° 2 : 02PM No, 0r,)'SECIRCL STORE LOCATION AT TOP <br />