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0109-2042-3wO,ll 14:13:17 07-11-2013 26/33 . <br /> 1 : WILSON _-IY TIRE CO., INC. . FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837 165204 - <br /> Way Tire WUson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US 77re Sales #24 US Tire Sales <br /> . on y .1535 Market St.. 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 209-571-5611 510-887-1261 916.395.2245 <br /> CUSTOMER P.O.# DATE <br /> j r- as- -iy <br /> PHONE VEHICLE# <br /> LICENSE <br /> i <br /> LOCAT N OF S VICE STATE ZIP CODE <br /> Za-< 0 1 �T) qO`-0l <br /> CUSTOMER TPID I — <br /> DECAL <br /> -1 t4 <br /> 1 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 falslflcatlon of <br /> this Information may result In suspension,revocallon,or donlal of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result in'civil penalties up to$25,000 par day,per violation of administrative penalties up to$5,000 per violation per day as described In Public Resources Cade sectlon 42962. <br /> DRIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •- • <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HU8' <br /> FF ' war<=>' <br /> 5 • — ---- --— —— ------- --- <br /> IM, <br /> QTY DESCRlPTlON OF WORK COM LETED QTY DESCRJPTIOAI OF INORft—OPLETED QTY. DESCRIPTION OF WDRK COMPLETED <br /> SERVICE CALL MOUNT I DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I 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 /> FINISH MILES: <br /> frzS' A1111146-1-15 START MILES: <br /> TOTAL MILES: <br /> START TIME: R AM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> •O ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> I] IMPORT FROM fl ❑WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY <br /> ❑ EXPORTTO AS ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> `c Dot4 I certify that under penalty of orJury under the laws of the Stale of California that the Information provided above is true and correct In addition,I <br /> JOS' am awaro that falsification of this Information may result In civil penalties up$25,000 per day, per vlolatlon yr administrative penalties up to <br /> o $5,000 per violation per day as described In Public Resources Code sectlon 42862, <br /> w <br /> CUSTOMER PRINT NAME CUSTOMEA SIGNATURE DATE <br /> FRe7ei�ved Trme)Jul 11, 2013 2 , 02PM No. 071 9ASECIRCLE STORE LOCATION ATTQ? <br />