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00* <br /> 14:12:42 07-11-2013 24/33 <br /> t / b WILSON AY TIRE CO., INC. FLEET SERVICE RECORD �1i'1�5 <br /> U.S. TIRE SALES 15 � `)—g TPID 1000837 16 5 0 4 0 <br /> V1 WNson Way Tire Wilson Way Tire Recap #02 Connell Tire 921 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 11 N.Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> :fockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 09-465-0281 209-465-3262 209-466.2561 109.571.5611 510-887-1282 916-3952245 <br /> USTOMER P.O.# DATE <br /> - 5)SP— <br /> PHONE VEHICLE# n ✓✓ <br /> LICENSE# <br /> OCATf OF SE VICE <br /> STATE e ZIP CODE <br /> C17 <br /> CUSTOMER TPIDDECAL# <br /> 1 15�Y7�J-Wb -tel ._ - �-7 <br /> I certify that under penalty of perjury under the laws of the State of California that the Information provided above Is We and correct.In additlon,I am aware that falsification of <br /> this Information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42860 and may <br /> result In civ Ities 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 /> iRIVER NAM DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •R • <br /> IAKE TRUCKM;ZAILER# LICENSE STATE ODOMETER/HUB <br /> 4-120-2 <br /> SPECIAL S� <br /> SPECIAL INSTRUCTIONS ON OFF <br /> C1 <br /> 4-ye e <br /> Qri DESCRIPT70N OF 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 I DISMOUNT(S)LOOSE ALUMINUM STEMS) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNTS) 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 /> PRODUCT <br /> QTY I DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES. <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME 0 AM PM <br /> OA'D AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑LEA EXEMPT &CITHER <br /> Ll AGRICULTURE ❑COMMON CARRIEPUBACK HAUL <br /> A1111CK UP LOAD PE <br /> � <br /> IMPORT FROM <br /> DELIVERY WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO ❑VOLUME CUBIC YARDS <br /> L)WEIGHT IN TONS <br /> c pQtO 1 cern tha undo pe Ity of perjury under the laws of the State of California that the Information provided above Is true and correct In addition,I <br /> am a are hat tai Ific lion of this Information may result In civil penalties up$25,000 par day, per violation or administrative penalties up to <br /> $5,00 per lolallo pe day as described in Public Resources Coda section 42962. <br /> m <br /> CUSTOME N N ME CUSTOMER SIGNATURE DATE <br /> :SR AIS. c C n n ^r ^ ;,E CIRCLE ETORE LOCATION AT TOP <br /> Received Time Ju1, 11. 201 2 , 02PM No, 071 ; <br />