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1-209-242-3051 14:16:14 07-11-2013 3/3 <br /> t : WILSON AY TIRE' CO., INC. FLEET SERVICE RECORD q11110 <br /> U. TIRE SALES <br /> b l b 8 03 rPID 1000837. 16 5 417 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire <br /> #21 US Tire Safes #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. <br /> Stockton,CA 85205 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd, <br /> Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 <br /> 209-465-0281 209-465-3262 209-466.2581 Hayward,CA 94545 Sacramento,CA 95823 - <br /> CUSTOMER 209-571-5611 510-887-1282 916-395.2245 <br /> P.O.# DATE <br /> e "l3 <br /> PHONE VEHICLE# <br /> LICENSE <br /> LOCATION F SERVICE <br /> STATE ZIP CODE <br /> CUSTOMER ePlDnal c Ory 1/' <br /> penalty f Perjury undo DECAL# <br /> L _ _ �JI <br /> r the laws of the State of California that the Information provided above Is true and correct In addition,I am aware lhatllflcatlon of <br /> this Information may result In suspension,re acatlon,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 l0$25,000 per day,her violation of administrative penalties up to$5,000 per violation per day as described In Public Resources Code sectlon 42962. <br /> DRIVER NAME DRIVER SIGNATURE <br /> X DATE <br /> • tell •- • <br /> MAKE TRUCKITRAILER# <br /> LICENSE STATE ODOMETER/HU8 <br /> SPECIAL INSTRUCTIONS' <br /> ON OFF <br /> CRIPTIo . <br /> QT1! <br /> %1 OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> QTY. DESCRIPTION OF WORK COMPLETE-L? <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 /> QTY• e, ,.�>..�. :: . • . <br /> MFG DESCRIP77ON FINISH MILES: <br /> START MILES: <br /> TOTAL MILES <br /> START TIME-. M <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: <br /> OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> _ ❑GOVERNMENT a LEA EXEMPT OTHER <br /> ❑AGRICULTURE C)COMMON CARRIER/BACK HAUL <br /> ICK UP <br /> C) IMPORT PE IMPORT FROM _ <br /> DELIVERY HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO <br /> ❑VOLUME CUM YARDS ❑WEIGHT IN TONS <br /> ,c Dolo I tort ha d p`nally of perjury under the laws of the State of Callfomla that the Information provided above is true and correct.In addition,1 <br /> `oc am aw re al i atlon of this information may result In civil penalties up $25,000 per day, per violation or administrative penalties up to <br /> $rut- ervlo day as described In Public Resources Code section 42962. <br /> i m <br /> CUSTOMER PRI NA E CUSTOMER SIGNATURE <br /> 'SQ AIA 1 AC; /[l 7 1� _ DATE <br /> Received T 'Irrle"Jul. 11, 20101 2 : 02PM No, �]I ECIRCLES ORE LOCATION AT TOP <br />