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/d 315�r�735- <br /> WILSON ' ' TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000337. 78,231 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #05 Wilson Way Tire X21 US Tire Sales '23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,Ca.95205 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Co.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209.465-0281 209-065.3262 209.466.2581 209-835.4087 209-571-5611 510.887.1282 916-395.2245 <br /> CUSTOMER .,� W 1D.0. # DATE <br /> � ��� P VEHICLE# <br /> Y 0 � 136a <br /> �� LICENSE# <br /> LOCATION OF SERVICE n' STATE ZIP CODE <br /> CUSTOMER TPID A F� y A � Lr�DECAL# <br /> I certify that under penalty of perjury under the laws of the State of California that the mformati provided above is true and correct.In addition,I am aware that falsification 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 or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •- • <br /> MAKE RUCK/T AILER # -S LICENSE STATE ODOMETER/HUB <br /> 1--lay, � L ,z4� e,01q <br /> SPECIAL INSTRUCTIONS ON OFF <br /> PD 130 <br /> DAkP#Qr- / 6h 5 3 1 - - <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> VICE 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. SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: q r <br /> START TIME: SCJ clt- Ate M <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> GOV RNM NT ❑ LEA EXEMPT ❑ OTHER <br /> -4 •-- AGRICULJURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑. ICK UP LO TYPE <br /> ❑ IMPORT FROMf 12>1� <br /> WHOLE TIRE COUNT [IWEIGHT IN POUNDS <br /> ❑ DELIVERY <br /> ❑ EXPORT TO ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> 1 certify that under alty perjury under the laws of the State of California that the information provided above is true and correct.In addition,I <br /> `orc DQIQTre am aware that falsificatl n of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> _ a $5,000 per violation per day as described in Public Resources Code section 42962. <br /> w m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 7 ,q r, `� 1 <br />