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1-209-242-3051 14:10:46 07-11-2013 18/33 <br /> i i- WILSON 16Y TIRE CO., INC. FLEET SERVICE RECORD 13 <br /> U.S. TIRE SALES I <br /> 1 5 a TPID 1000837. 164711 <br /> 1lson Way Tire Wilson Way The Recap #02 Connell Tire 421 US Tire Sales #23 US Tire Sales #24 US Tire Sales .' <br /> N.WNson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd, 1915 National Ave 6530 Franklin Blvd: <br /> Stockton,CA 95205 Sfockton CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 20.9-465-0281 209-46; 262 209-466-2581 209-571.5611 510-887-1282 916-395-2245 <br /> �USTOMER P.O.# DATE <br /> PHONE VEHI LE# <br /> ` LICENSE# lo - <br /> OCATI OF SE VIC �O - STATE ZIP CODE <br /> _0q <br /> CUSTOMER TPID 1 1C DECAL# <br /> I cern formatio fy that der penalty of perjury under the laws of the Stale I f California that the Information provided above is true and cortecL� —� i <br /> this p ry p rY addition,I em aware Ih alslfl Ion of <br /> q n may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result in clvll alties up to$25,000 per day,per violation of administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> )RIVE( KFIE DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER VEHICLE INFORMATION <br /> TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> sq- s C" <br /> SPECIA`INSTRU T10N8 , <br /> ON OFF <br /> S �L = w�- - - --- --- - - - --_ ---.------ <br /> C V-e 1� S ( �Q�6'1 Q-�/� <br /> QTS! mvD_-lyF(jF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT I DISMOUNT(S)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(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> Sul <br /> i <br /> Q MFa DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: - O AM PM <br /> ON SITE TIME: AM PM <br /> r <br /> OUTTIME., AM PM <br /> FINISH TIIyE: AM PM <br /> AD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> /► •�_ ❑ GOVERNMENT ❑LEA EXEMPT 4D<THER <br /> —E ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP LOA PE <br /> ❑ IMPORT FROM <br /> ❑DELIVERY HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑.EXPORT TO '. ` O VOLUME CUBIC YA9DS ❑WEIGHT IN TONS <br /> pot I certify that under penalty of perjury under the laws of the State of California that the Information pr Idled above Is true and correct.In addition,I <br /> am aware that falsification of this Information may result In civil penalties up$25,000 per day, pe 4lolalion or administrative penalties up to <br /> S5,000 per violation per day as described In Public Resources Code section 42962. <br /> w $ <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FCD AL. -tom'A �7 r- -1 ISE CIRCLE ORE LOCATION AT TOP <br /> Received Tirne Jul, 11, 20101 2 : 02PM No, 071 ` ' <br />