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I <br /> Q-- - <br /> FLEET SERVICE RECORD WILSON WAY TIRE CO., INC. j <br /> U.S. TIRE SALES k j I1� I <br /> i WlJson Way lire N?lson Way The Recap TPID 1000837. 16 g 18 g <br /> 1 N.Wilson Wey 1535 Market SL A #02 Connell 17re 021 US Tire Sales <br /> 3ckton,CA 85205 2211 N. <br /> Wl13on Way 2600 Yosemite Blvd. #23 Af flo Sales 024 US T7ra Sales <br /> Stockton,CA 95205 Stockton,CA 85205 1915 NeIonelAvo. 6530 Franklin Blvd. <br /> 9-465-0281 709.465-3262 Mode3fo,CA 95J54 <br /> 209 466•Z581 209.571-5611 Heyward CA 94545 Sacramento,CA 85823 <br /> STO FR 510.887-1282 918.395.2245 <br /> P.O'14 DATE <br /> 333 0-2y - 20/5 <br /> PHONE FVEHICLE#::::�����SE# <br /> CATION O SE ICE-rx1 ` <br /> S �N� STATE ZIP CODE <br /> NN � r <br /> CUSTOMERTPID { ¢'' <br /> DECAL# � (. —I0 �v � �� � 1 <br /> I certify that under penalty caperjury under the laws of the State of Callfomla that the information provided above is true and correct In addition,I am ewers that falslficatlon of <br /> thin It In civil <br /> may vault In 5,000 per <br /> d revocation,or danial of renewal of the Waste Tire Hauler Registration punuent to Public Resources Code section hat fe and may <br /> result In dull panslilaa up to f2S,000 par day,per violation of administrative penaitles up to Opo per violation par day a t described a Public Resources Code sealer 42962 <br /> :IVER NAME <br /> fC DRIVER GN DATE /l <br /> EKE / 1 J • X • w <br /> � TRUCK/TRAILER p LICENSE <br /> 3/i1 � STATE ODOMETERIHUB <br /> X11 / <br /> SPECIAL INSTRUCTIONS t <br /> ON <br /> 5,6 44 7 10 <br /> ITy. DESCf71P NOFWORKCOMPLETED QTY OEBCRlPT70NflFW01;}(COMPLETED <br /> SERVICE CALL QTYDESCRfI ION OF WORKCOMPLETEbT- <br /> 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) <br /> VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) <br /> REPAIR MATERIAL(S) S <br /> LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> (TIRES)BALANCED <br /> WHEEL SWITCH(S) METAL VALVE CAP(S) <br /> RECONDITIONED WHEEL(S) 0 RING(S) <br /> ]TY. ••a e <br /> N FINISH MILES: <br /> - Mf1 V rj START MILES: <br /> TOTAL MILES: <br /> START TIME: Ph, <br /> ON SITE TIME: APA Phi <br /> OUT TIME: _ Aha Phi <br /> DAD AMOUNT FINISH TIME: r3 Ah M <br /> HAULER EXEMPTION IF APPLICABLE❑LE <br /> (]GOVERNMENT A EXEMPT ❑OTHER <br /> ICK UP <br /> ❑AGRICULTURE COMMON CARRIER/BACK HAUL <br /> I� � <br /> ❑ IMPORT FROM GvrOr fs <br /> J'/DELIVERY - WHOLE TIRE COUNT <br /> ❑ EXPORT TO Q WEIGHT IN POUNDS <br /> ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> o�c norQ+ I certify that under penalty of pequry under the Inw/of the State of California that the Information provided above Is true and correct.In addition,I <br /> y em aware that falsification Of this inlormatfon may result In civil panaltlse up f25,000 per day,per vloleUon ar administrative penalties up to <br /> �' f5.000 pervfolailon parday as descred In Public Resources Code se <br /> 1w wibction 42982. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE <br /> 'SR No. 169189 DATE <br /> IE G0 (�LE-ASE ('ROLE STORE LOCATION AT <br /> 9�Z DIOZ-£0-10 EE� <br /> 1S0E-ZVZ-60Z-L <br />