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1-209-242-3051 14:15:54 07-11-2013 2/3 <br /> WILSON 4 _ .Y TIRE CO., INC. <br /> U.S. TIRE SALES FLEET SERVICE RECORD <br /> blb55 _5 TPID 1000837 16 5407 <br /> 101 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire <br /> #21'21 N.Wilson Way 1535 Market St. 260 US Tire Sales 023 US 77re Sales #24 US Tiro Sales <br /> ltockton,CA 95105 Stockton,CA 95205 2211 N.Wilson Way 2600'1 Yosemite Blvd. 1915 National Ave, 6530 Franklin Blvd. <br /> 09-465.0281 Stockton,CA 95205 Modesto,CA 95354 Hayward, CA 94545 <br /> 209.465-3162 209-466-2581 Sacramento,CA 95823 <br /> USTOMER 209-571-5611 510-887.1182 916-395-2245 <br /> P.O.# DATE <br /> PHONE VEHICLE;F <br /> LICENSEjY <br /> SCA N.OF RVICE (/f! Of <br /> /' <br /> STATE ZIP CODE <br /> CUSTOMER TPID � I _' <br /> Vj�� <br /> DECAL#�/� � <br /> I certify that under penalty of perjury under the laws of the Shale of California t (/ <br /> this information atun may result In suspension,revocation,or dental of renewal of the tthWaste In p Tire Hauler Registration pursuant to r-e Resources Code section 42960 alnd may <br /> resulton a1 <br /> resu t In civil penalties up!0$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 /> tIVER NAME. <br /> DRIVER SIGNATURE DATE <br /> X <br /> kKE TRUC RAILER# <br /> �OLICENSE STATE ODOMETER/HUB <br /> .Y; :. i �;:5+•' IL3L.•1lV �1�/I Ik1 NJ7 <br /> [ ON OFF <br /> --------------- <br /> 0 y�o � <br /> ITy c4 ;1� L�N'T ('dMPLET�D :—, Q _DESCRIPTION OF WORK COM�? — <br /> SERVICE CALLA�rGB�'TdQN=OEtyORKCOMPLETED_ <br /> MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEMS) <br /> FLEET INSPECTION �Ig10UNT/DISMOUNTS <br /> DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) <br /> VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT 5) <br /> ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) (TIRES)BALANCED <br /> METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> rY -�� ( ) <br /> / t3 DESCRIp9T0­N FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: n <br /> C2 START TIME f/ qhf Pit <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> 4D AIUIO�JNj FINISH TIME: AM PM <br /> —7 HAULER EXEMPTION IF APPLICABLE <br /> _ ❑GOVERNMENT EJ LEA EXEMPT HER <br /> ❑ GRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP <br /> CJ IMPORT TY IMPORT FROM � '� <br /> DELIVERY HOLE TIRE COUNT <br /> LJEXPORTTO ❑WEIGHT IN POUNDS <br /> ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> 6c Dar, I certify that under penalty a Perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,I <br /> ri am aware that falsification of this Information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> 35,000 per violation porday as described in Public Resources Code section 42062. <br /> m <br /> CUSTOMER PRINT NAME �--- <br /> CUSTOMER SIGNATURE DATE <br /> RRece1v d T1me�Ju1. 11. 2013 2 : 02PM No. 0 719 CIRCLE STORE LOCATIoNATTnp <br />