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1-209-242-3051 14:14:53 07-11-2013 31 /33 <br /> r r t WILSON VOY TIRE CO., INC.U.S. TIRE SALES rLEET SERVICE RECORD <br /> � w // -- <br /> W ILP TPID 1000837. 16 5 4 0 2 <br /> 41 Wilson Way Tire Wilson Way Tire Recap 002 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 21 N.Wilson Way 1535 Market SL 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> tockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 09-465-0281 209-465.3262 209466-2561 209.571-5611 510-687.1282 916-395-2245 <br /> USTOMER P.O.# <br /> DATE n / <br /> r / ! V <br /> PHONE VEHICLE# <br /> LICENS <br /> DCATI OF 5 CE STATE <br /> . ZIP CODE <br /> CUSTOMER TPIDI DECAL# <br /> � <br /> - Id-JSIJ <br /> I certify that under penalty of perjury under the laws of the State of California that the Information provided above Is true and corrocL In addition,1 am aware that falsiflcallon 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 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. <br /> RIVER NAME12 DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •R • <br /> AKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> Im— // 7 el ' <br /> SPECIAL INS RUCTIONS , ON OFF <br /> QTY. DESCFUPT169 OF WORK COMPLETED Q j F IP770N OF WORK COMPLETED QTY. DESCR1P77ON 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 /> QTl r" - MSG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME. AM PM <br /> FINISH TIME: AM PM <br /> OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> •�_ ❑GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> AG R I C U L-tb R I- ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> [I IMPORT FROM—pp <br /> ADELIVERY WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> LJEXPORTTO 0 VOLUME CUBIC YARDS <br /> 1 (J WEIGHT IN TONS <br /> o�,c DataT' 1 certify lhaunder penalty afpel)ury under the laws of the Slate of California that the information provided above Is true and correct,In addition,I <br /> a wa at falsiflcadon of thl�lnformation may result In civil penalties up $25,000 per day, per violation or administrative penalties up to <br /> 0 pe v IatlonperdgyasdescribedInPublicResourcesCodesection42962. <br /> 4 CUSTOM PRINT AME CUSTOMER SIGNATURE DATE <br /> :SRecely d Time+Jul 11, 2013 2 , 02PM No, O]1 )3ECIRCLESTORELOCATIONATTOP <br />