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1-209-242-3051 14:13:57 07-11-2013 28/33 <br /> r t : WILSON&Y TIRE CO., INC. FLEET SERVICE RECORD (J1011) <br /> U.S. TIRE SALES <br /> L ��, 5 1 p� <br /> l 3 TPID 1000837 165225 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales <br /> #23221 N.ti/son Way- 1535 Market SL 191 N Tiro Sales #24 US Tire Sales <br /> 2211 t Wilson Way 260D Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 85105 Stockton,CA 85205 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 510-887-1282 916.395.2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# / <br /> LICENSE# <br /> LOCATIOt)OF SERV E STATE <br /> ZIP CODE <br /> CUSTOMER TPID DECAL# <br /> I certify that under penalty o}parJury under the laws 0f the State of California that the Information provided above Is true and correct.In addition,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 Coda section 42960 and may <br /> result In civil pens up to$25,000 per day,per violation of administrative penalties up to 55,000 per violation per day as described In Public Resources Code section 42952. <br /> DRIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> sR0 <br /> MAKE. TRUCKl1 RAILER# LICENSE STATE ODOMETER/HUB <br /> rSPECIAL INSTRU� C ,ON --- ------ __ OFF------ - <br /> _.. _ <br /> ►� o(� <br /> CITY DESCR/PTiONOFW6 '4 011FL 7£D 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) 0 RING(S) <br /> -1 <br /> ull <br /> »>.w.. FINISH MILES: <br /> START MILES: <br /> L <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: -C' AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> / _ Q GOVERNMENT Q LEA EXEMPT Q OTHER <br /> ❑AGRICULTURE Q COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> ❑ IMPORT FROM <br /> DELIVERY WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO <br /> ❑VOLUME CUBIC YARDS Q WEIGHT IN TONS <br /> ,c porQ I certify that under penalty of perjury under the taws of the State of C Ilfornla that the Int aUon p vlded above Is true and eorract.In addition,I <br /> Joh T. am aware that falsification of this Information may raeu c vll naltlea up$25,00 p r day, er v elation or administrative penallles up to <br /> d $5,000 per violation per day as described In Public Reso es Ca a tlon42962 <br /> 9 � <br /> • CUSTOMER PRINT NAME STOMER SIGN TUR (, D <br /> D TE <br /> FSR Nn 1 Cr,2 7 r SSE CIR LE STORE LOCATION AT TOS <br /> Received Time Jul. 11. 2013 2 ; 02PM No, 0719 <br />