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Z.CO(aO 131 z5-g2-7 <br /> t, WILSON ' Y TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES <br /> TPID 1000837. 83267 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #05 Wilson Way Tire #21 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,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209465-0281 209.465.3262 209-466.2581 209-8354087 209-571.5611 510-887-1282 916-395.2245 <br /> CUSTOM �i / / P.O. # DATE Vn ` <br /> PHONE VEHICLE <br /> 2/l <br /> �i bL LICrW 7g �Y <br /> LOCATION OF SERVICE/ STATE /.-� ? 'i I <br /> eE <br /> CUSTOMER TPID �'- T 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 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 ,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER <br /> IVER GNATURE DATE f <br /> CUSTOMER - • <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY. DESCRIPTION OF WORK 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 DISMOUNTS) 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 /> QTY. SIZE MFG 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 /> LOAD AMO NHAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> -- • ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LO D TYPE <br /> ❑ IMPORT FROM HOLE TIRE COUNT E:1 WEIGHT IN POUNDS <br /> ELIVERY <br /> ElEXPORT TO ( p��r ❑ VOLUME CUBIC YARDS ElWEIGHT IN TONS <br /> Dalp I certifyat and natty of perjury under the laws of tlNe State of California that the information provided above is true and correct.In addition,I <br /> m~oi:, — 7rQN am awar that f'Isific tion of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> . $5,000 pi-viola ion p r day as dei cribed in Pub iJ�c Resources Code section 42962. <br /> m <br /> m , <br /> 9'- <br /> CUSTOMER PRINT ME �CUSTOMER�GNATURE DATE <br /> FSRNO. V 2 6 7 Jro r.e.r-_ _ ,____._---.--. ---- <br />