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1-209-242-3051 14:11:05 07-11-2013 19133 <br /> WILSON AY TIRE CO., INC. FLEET SERVICE RECORD61 1 0 <br /> / <br /> 11 U.S. TIRE SALES _ 1 l 15 a TPID 1000837 16483%19 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tiro Sales #23 US Tlro Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd, 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 9582: <br /> 209-465-0181 209465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE#11-�2 112 <br /> LICENSE# <br /> LOnN OF SERVICEp STATE i+ n ZIP CODE <br /> CUSTOMER TPID —�r N{, l� <br /> I certify that under penalty of perjury under the laws of the Stale o1 Callfornla that the information provided above Is true and correct.In addition,I am award that falsification of <br /> this Information cIvI ion may result In suspension,revocation,or denial of renewal of the Waste The Hauler Registration pursuant to Public Resources Cade section 42960 and may <br /> result In clyll ndltles up to 525,000 per day,per vlolatlon of administrallve penalties up to 55,000 per violation per day as described In Public Resources Code section 42962. <br /> DRIVj R NAME / DRIVER SIGNATURE DATE <br /> fVl x <br /> INFORMATIONCUSTOMER VEHICLE <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> 5- C <br /> FE9�1 'INT� 1GTi0t8� <br /> r �: <br /> ON - <br /> � OFF <br /> t�lS ��(, t tom—�— � -------- --------------- --- <br /> QTY DD3GlZIpT10is1 OF NQRif COMPLETED L•}TYDESCRIP77ON OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <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 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 /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> Q sl " i„.,wV R$F DESCRIPTION FINISH MILES: <br /> G1�/ START MILES: <br /> TOTAL MILES: <br /> START TIME: PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> —_ • ❑GOVERNMENT ❑ LEA EXEMPT OTHER <br /> AGRICULTURE ❑COMMON CARRIEPUBACK HAUL <br /> PICK UP LOAD PE <br /> ❑ IMPORT FROM <br /> DELIVERY n HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> L) EXPORT TO j t7�� ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> Dole, I certl th t under ena of perjury under the laws of the State of Callfornla that the information provided above Is true and correct.In addition,I <br /> e� a aw ra hat fats cati n of this Information may result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> -1 $ ,000 r lolatton rd asdescribedlnPublic Resources Code section 42962. <br /> � m <br /> CUATOMER PR A E\- CUSTOMER SIGNATURE DATE <br /> rremc . r q n r -ORE LOCATION AT TOP <br /> Recei.v_ed Time Jul, 11, 201 2 . . 2i -'w ��'_ .�l' ',;ASE CIRCLE S <br />