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1-209-242-3051 14:12:59 07-11-2013 25/33 <br /> WILSON {Y TIRE CO., INC. FLEET SERVICE RECORD qt((1 13 <br /> U.S. TIRE SALES b ` 5 ?J„ 1 TPID 1000837 16 5 0 4 6 <br /> #01 Wilson Way Tire Wilson Way Tire Recap 1102 Connell Pre 421 US Tire Sales I #23 US Tire Sales #24 US Tiro Solos <br /> 221 N.Wilson Way 1535 Marko!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 95823 <br /> 209-465.0281 209-465-3262 209-466-2581 209.571-5511 510-887-1282 916-395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> OCATIO _ SERVICE <br /> STATE C a n ZIP CODE <br /> CUSTOMER TPID I —�� F— <br /> DECAL# — <br /> 1 certify that under penalty �perdjuryundo the laws of the Stato of California that the Information provided above Is true and correct In addition,I am aware 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 42960 and may <br /> result In civil pe aitlos up to$25,000 per day,per violation of administrative penalties up to$5,0110 per violation per day as described In Public Resources Code section 42962. <br /> IVER NAME DRIVER SIGNATURE DATE <br /> ,2_42 <br /> X <br /> • OR • <br /> u1AKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> -75q2. 5 ' 9 <br /> SPECIAL INST141.115TIONS ' ON OFF <br /> 07J! DESCRIP770N aF WY'tfskrOMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPT70N 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 /> PRODUCT <br /> QTY SI2 MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> ' 11 TOTAL MILES: <br /> Y V START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: AM M <br /> _ ADA UNT HAULER EXEMPTION IF APPLICABLE <br /> n _ ❑GOVERNMENT C)LEA EXEMPT OTHER <br /> +� ❑AGRICULTURE ❑COMMON CARRIEPUBACK HAUL <br /> PICK UP ,9 LOAD PE <br /> ❑ IMPORT FROM 4�,,a <br /> DELIVERY HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO /ae. AA�- ❑VOLUME CUBIC YARDS <br /> ❑WEIGHT ITONS <br /> Data I certify that andtNE <br /> al of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,1 <br /> o� o: am aware that do of this information may result In civil penalties up $25,000 par day, per violation or administrative penalties up to <br /> $5,000pervlolar a aados IbodInPublic Resources Code aectlon42962_ <br /> CUSTOMER PRINT CUSTOMER SIGNATURE DATE <br /> FCR AL, 1 CC J n c SE CIRCLE F"ORE LOCATION AT TOP <br /> Rer-eived Time Jul, ll. 2013 2 : 02PM No, 071c� <br />