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42-305 <br /> 1-209-2 1 14;15:11 07-11-2013 32/33 <br /> M <br /> 1 r. <br /> WILSON 14Y TIRE CO., INC. FLEET SERVICE RECORD kll�l3 <br /> U.S. TIRE SALES <br /> TPID 1000837 165403 <br /> #01 Wilson Way Tire Wilson Way T7re Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tiro Sales <br /> 221 N.WAson Way 1535 Market St. 2211 N. Wilson Way 2600 Yosemite Blvd. 1915 NaflonalAve. 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 209-465-326 209-466-2581 209-571.5611 510.887.1282 916.395.2245 <br /> :USTOMER P.O.# DATE p <br /> PHONE V HICLE# <br /> LICENSE# <br /> .00ATI OF SER CE STATE ZIP CODE <br /> r1l t3 7 - <br /> CUSTOMER TPID <br /> DECAL# <br /> I certify that under penalty of perjury under the laws of the State of California that the Information provided above Is true and torr t In addition,I am aware that falsification of <br /> thio lnfonnatlon 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 NAME DRIVER SIGNATURE DATE <br /> X <br /> INFORMATIONCUSTOMER VEHICLE <br /> RAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> ° SPECIAL INSTRUCTION ON OFF <br /> QTY.', UESCRDtPN DP VMRK COMPLETED QTY. 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 /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> 7771 <br /> -s..-` ftIFO FINISH MILES: <br /> D S ON <br /> START MILES: <br /> TOTAL MILES: <br /> S START TIME: C7 <br /> AM PM <br /> ON SITE TIME: AM RMoel . <br /> OUT TIME: AM PM <br /> � v <br /> FINISH TIME AM PM <br /> _OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ——_ _ ❑GOVERNMENT []LEA EXEMPT OTHER <br /> ❑AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ICK UP n LC1Ab T' E <br /> C] IMPORT FROM CCS <br /> DELIVERY HOLE TIRE COUNT (JWEIGHT IN POUNDS <br /> ❑ EXPORT TO ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> c Dale IA <br /> Ity that ander penalty of perjury under the laws of the State of California that the information provided above Is true and correct In addition,I <br /> ,od �� aawa that falsification of this Information may result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> OOp r IolationperdayasdescribedInPublicResourcesCodesection42962- <br /> R � <br /> • 4STR PRINT f�IAME CUSTOMER SIGNATURE DATE <br /> F,-Recerived TimeQJuhll, 2 " 2 : 02PM No, 0711)SECIRCLE STORE LOCATION ATTOP <br />