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01-201.-212-3051 14:13:37 07-11-2013 27/33 <br /> WILSON AY TIRE COINC. FLEET SERVICE RECORD i4t i) <br /> U.S. T/RE SALES Y E'I" TPID 1000837. 165223 <br /> #Of Ypson Way Tire Wit-son Way Tire Recap #02 Connell The #21,.U$TIre.Sales -#23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 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 510.887.1262 916.395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCAT OF RVICE O STATE /I /1 ZIP CODE <br /> CUSTOMER TPID <br /> I certify that penalty of perjury under the laws of the Stats of Callfomla that the Information provided above le true and correct.In add1llon,I am aware that fafslfic-anon of <br /> this Info rmatlon <br /> ion m may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler ReglsttaUon pursuant to Public Resources Code section 42960 and may <br /> result In civil penalties up to$25,000 per day,per vlolallon of admintatrallve penalties up to 55,000 per vlolatlan par day as described In Public Resources Code sactian 42962. <br /> DRIVER NAME 0/1 DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •• • <br /> MAKE TRUCKRRAILER# LICENSE STATE ODOMETER/HUB " -?= <br /> olg-W-•� � -T p �/ U•�-- • <br /> _ �� ---- --OFF <br /> QTY. I�1 SCR1 ,. A ,t S�rfF'R 7ED Y3 I,'" <br /> tjESCR/PT/t7N OF VVdf7IF Cgh4Ft LTI✓=D, QTY. OESCR/PT1 N OF WORK COA+t .. <br /> SERVICE CALL MOUNT I 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 RINGS) <br /> PRODUCT rt <br /> O „t,, <br /> ...s r t r” DFSti p11 FINISH MILES: <br /> e —Fv START MILES: <br /> TOTAL MILES: <br /> 0 Pre-5 START TIME:_^ PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> �C FINISH TIME: 10 PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT Q LEA EXEMPT J810THER <br /> AGRICULTURE Q COMMON CARRIER/BACK HAUL <br /> PIC OIMPORTFROM <br /> rLOAe <br /> TIRECOUNT ❑WEIGHT IN POUNDS <br /> DELIVERY❑ EXPORT TO �y� A // E CUBIC YARDS Q WEIGHT IN TONS <br /> ��DatQ I certify that under penalty of perjury under the Iowa of the State of Catifornia that the Information provided above Is true and correct.In addition,I <br /> Soo r.� am aware that falsification of this Information may result In civil penalties up 525,000 per day,per violation or administrative penalties up to <br /> $5,000 perviclatlon per day as descrlbed In Public Resources Code section 42862. <br /> w � <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> rR e c e i v ed T irne!)J u 1 11, 2013) 2 ; 0 2 P M No, Q]1 t):ASE CIRCLE STORE LOCATION AT TOP. <br />