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1-209-242-3051 14:11:43 07-11-2013 21 /33 <br /> oil. WILSON V* TIRE CO., INC. , LEET SERVICE RECORD �I'!t3 <br /> U.S. TIRE SALES j L{ 1. C) TPID 1000837 165001 <br /> 1 Wilson Way Tire Wilson Way Tire Recap 902 Connell Tire #21 US Tire Sales #IJ US Tire Sales #24 US Tire Sales <br /> 1 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd, 1915 Naflonal Ave. 6530 Franklin Blvd, <br /> ockfon,CA 95205 Stockton,CA 95205 Stockton,CA 85205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 9-465-0281 209-465-3262 209-466-2581 209.571.5611 510.887-1282 916-395.2145 <br /> ISTOMER <br /> P.O.# DATE <br /> PHONE VEHICLE# / <br /> LICENSE# <br /> ,�',* <br /> ZICAT O;Fg:RVICE <br /> STATE ZIP CODE <br /> CUSTOMER TPID DECAL# <br /> certify that under penalty of perJury under the laws of the State of California that the Information provided above Is true and correct In addition,1 am aware that falsification of <br /> this Information may result In suspension,revocation,or donlal of renewal of the Waste The Hauler Registration pursuant to Public Resources Cods section 42960 and may <br /> result In civil pen Iles up l0$25,000 per day,per violation of administrative penalties up l0$5,000 per violation per day as described In Public Resources Code section 42962. <br /> LIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> lKE TRUCEUTRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> 19 -- ----- - <br /> )TY DESCRIPTION OF WORK COMPLETED CITY. DESCRIPTION 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 /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> pit <br /> _ MFG DESCRIPTION <br /> )TY FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: <br /> ON S1TE TIME: AM PM <br /> OUT TIME: /^� AM PM <br /> / FINISH TIME: ✓ PM <br /> )AD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT A EXEMPT 2tTHER <br /> — A ❑AGRICULTURE COMMON CARRIER/B CK HAUL <br /> r;PICK UP LOA PE <br /> F ❑ IMPORT FROM <br /> IDELIVERYWHOLE TIRE COUNT (:jWEIGHT IN POUNDS <br /> ❑ EXPORT TOIt I'vi ❑VOLUME CUBIC YARDS 0 WEIGHT IN TONS <br /> c pato I certify that under pe I of edury under the laws of the State of Callfornla that the Information provided above Is true and correct.In addition,I <br /> �d T, am aware that felaltic tla o thf Inf in ti n may result In civil penalties up $25,000 per day, per violation or administrative penalties up to <br /> $5,000 per vlolatlonps day ac es rib In Public Resources Code section 42962. <br /> r�CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> SrRecelved Tire�Jul, 11, 2013 2 , 02PM Nn, Q]IECIRCLE ETORELOCATION ATTOP <br />