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WILSON YTIRE INC. � �' ` Zyq�7 <br /> (WE) <br /> CO., FLEET SERVICE RECORD <br /> U.S. SIRE SALES TPID 1000837. 8 3 2 6 6 <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 /> 209-465.0281 209-465.3262 / 209.466-2581 p 209-835.4087 209-571-5611 510-887-1282 916.395.2245 <br /> DATE <br /> . # <br /> (�Y 6-x- SS P.O <br /> CUST R /o <br /> PHONE VEHICLE <br /> LICEN E#OLAI�l 2 9 <br /> LOCATION OF SERVICE STATE <br /> CUSTOMER TPID <br /> DECAL# <br /> I certify that under penalty of perjury under the laws of the State of California that the informal' 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 ler 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 t 5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAMEfeeJ/'L.',eC/ DRIVER WNATURE DATE <br /> CUSTOMER VEH CLE INFORMATION <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> ...... ------ - ...- ---.......... - <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 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 /> PRODUCT INSTALLED <br /> QTY. SIZE IMFG 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 AMOU HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> -- -- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> E] IMPORT FROM HOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑ EXPORTTO�S 65', � ,A/ ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> Datq I certify that under penalty of perjur under the laws of the State of California that the information provided above is true and correct.In addition,I <br /> mor` fro am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> $5,000 per violation per day as described in Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CU OMER SIGNATURE DATE <br /> FSR No. <br />