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1-209-242-3051 14:12:05 07-11-2013 22/33 <br /> WILSON aY TIRE CO., INC. FLEET SERVICE RECORD y[11113 <br /> U.S. TIRE SALES ' t' 1111 TPID 1000837 16 5 0 0 3 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US nre Sales #24 US Tire Sales <br /> 211 N.W lSon 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 95623 <br /> 209.465-0281 209-465-326 209466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER/ P.O.# DATE J / <br /> Q l <br /> PHONE VEHICLE# D <br /> r� <br /> LICENSE# ?X' <br /> LOCA OF S�R�VGE _® STATE ZIP CODE <br /> CUSTOMER TPID �1— <br /> —' DECAL# <br /> I certify that under p ally of perjury under tlaws of the Slat® f Calllomla that the Information provided above Es true and correct.In addition,1 am aware that falsification of <br /> this information may result in suspension,revocation,or denial of renewal of the Waste The Hauler Registration pursuant to Public Resources Code section 4296D and may <br /> result In civil pe es 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 41962. <br /> DRIVER NAME j DRIVER SIGNATURE DATE <br /> CUSTOMER VEHICLE INFORMATIONU <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> Cd- <br /> SPECIAL IN&TflUCTIONS , ON OFF <br /> ... .... ..... <br /> Y �t v p <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. 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) O RING(S) <br /> -Or r <br /> (Tr 'KI . Ml'O DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> STARTTIME: AM M <br /> ON SITE TIME: AM PM <br /> r <br /> OUT TIME: AM PM <br /> FINISH TIME/&'i AM <br /> LO D A OUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑LEA EXEMPT OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP LOA E <br /> [ ❑ IMPORT FROM HOLE TIRE COUNT CJ WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑ EXPORT TO r ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> c Dote 1 certify that under dbp1ty oferf u or the laws of the State of California that the information provided above Is true and correct.In addition,I <br /> od T� am aware that talc flc lion o th! Inf atlon may result in civil penalties up 525,000 per day, par vlolatlon or administrative penalties up to <br /> d $5,000perviolatlo pe day as es rlbe ubllcResources Code section 42982. <br /> m <br /> CUSTOMER PRINT NA CUSTOMER SIGNATURE DATE <br /> ^77 2 ASE CIRCLE TORE LOCATION AT TOP <br /> Received Time) Jul, 11. 2013 2 : �0! PM No. 0719= c <br />