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1-209-242-3051 14:14:34 07-11-2013 30/33 <br /> WILSON WATIRE CO., INC. t l_tET SERVICE RECORD 4111) <br /> U.S. TIRE SALES (� 1C� 55U TPID 1000837 16 5 2 4 8 <br /> �. <br /> Wlison Way Tire, Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> N.Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 NatlonafAve. 6530 Franklin Blvd. <br /> :kton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto, CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 465-0281 109-465-3262 209466-2581 209.571-5611 510-887-1282 916.395-2245 <br /> TOMER P.O.# DATE <br /> r r <br /> PHONE VEH LE# <br /> LICENSE' <br /> 4 NOF SE ICE � _.. STATE ZIP CODE <br /> :USTOMER TPID i DECAL# <br /> J <br /> certify that under penalty of perjury under the laws at the St, <br /> a of California that the Informatlan provided above Is true and correct.In addition,I am aware that falsification of <br /> ils Information may result In suspension,revocation,or dental of renegial of the Waste 71ra Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> esult In civil penalties 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. E <br /> ER NAME / DRIVER SIGNATURE� X DATE <br /> CUSTOMER •R • <br /> TRUCIVTRAILER# LICENSE STATE ODOMETER/HU I <br /> -75q 4221- 7 I <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> )C,tl <br /> C.) Ll Q <br /> � <br /> Y. OESCR/PT10N OF WORK COMPLET7=bQTY. DESCRIPTION OF RK COMPLETED 0TY,, DE JPTION 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 /> --rCTINSTALLE• <br /> Y. ~"S MFt3 DESCRIPTION FINISH MILES; <br /> START MILES: <br /> TOTAL MILES: <br /> • START TIME: PM <br /> ON SITE TIME: AM PM <br /> A OUT TIME: AM PM <br /> !l FINISH TIME: PM <br /> kD AMOUNT — HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑LEA EXEMPT THER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP p LO TYPE <br /> ❑ IMPORT FROM CJ <br /> DELIVERY WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORTTO �- ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> V <br /> c Dare 1 certify that under penalty of perjury under the laws of the Slate at Calitomia that the Information provided above Is true and correct.In addition,I <br /> A am aware t fat (1 tion of this Information may result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> $S,000parvl Ion a da asdescrlbedInPublic Resources Code section 42962. <br /> 0 <br /> CUSTOMER PRINT AM CUSTOMER SIGNATURE DATE <br /> >tR KI" C �'7 C <br /> Received Time Jul, 11. 2013 2 , 02PM No, 0719=: IRCLE STORE LOCATION AT TOP <br />