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Apr. 24. 2008 - 2:45PM :; .,CO ELL TIRE/GOLDEN STATE TRUCK No. 64$1 P. 9
<br /> WILS AY ME CO., INC. FLEET SERVICE RECORD
<br /> FIRE SALES TPD 100087.0 99 3 7 3
<br /> #Ot Wilson Way Tire N►9see Way 7Ire,ilow 0
<br /> 2'eonne9'Trre a 05,w it""way Tine t21 US"re Setas 0"US Tire Safes om us Tire Sefee
<br /> 42f N.MAN"Way 1939 ltfartret.Sf.`•': .. .. z2}�i�H.Wilson grey 1 i39 W.Eloi ontS SL 2909 Posemrte 8ivd- 19f5 iYaffodal Ave, am rlankttn Blvd.
<br /> stoGlaon,Ca.95205 SWekton,Ca.99295. . .31oektonCe.95203 Tracy,Co.,95.776 Modesto,CA,99964 Neywerd Cu.949'45 Sacramento,CA."A2a
<br /> Y09.499.9Y9iYDa-46$-�'�2 2f�B-466,ZSi1 209.9?9-�t097 249-5 !•4611 510-874282 918-39512M
<br /> CUSTO r . 4f,. ,.,.,;. . P.O. # DATE 0 -7
<br /> NA OtQ
<br /> PHONE VEHICLE# 1 1 9
<br /> LICENSE#Vy
<br /> LOCATION OF SERVICE t y� STATE ZIP CODE
<br /> CUSTOMER PID ! vel w :i a DEC
<br /> TRIP AL# —
<br /> I his certify chat under,ptinalry oTpeY�il(y�;ilnderaFie taws of the Stat6.of California that the Information provided above Is true and correct.In addition,I am aware that falsification of
<br /> tInformallon..may.':re9uR In;suspension,revocatlon.or(denial of r9rewal of the Waste Tire Hautsr Regietratlon pursuant to public Resources Code stiction 42960 antl may
<br /> result in civil penalHea up,25 3x6,Gt1`i F!d"y ..:"vf'ufatiLt4:or adrtiinlstrative penalties up to$5,000 per vlofation per day as described In Public Romirces Code section 42952.
<br /> DRIVER M DRIVER SIGNATURE DATE
<br /> MAKE TRUC AIL (�# LICENSE STATE ODOMETER/HUB
<br /> . AN ft
<br /> Ins Z 4-awl
<br /> Y SERVICE.CALC I. MOUNT 1 DISMOUNT(S)ON VEHICLE BRASS VALVE STEMS)
<br /> FLET;INSPECTIQN. MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S)
<br /> AIR SERVICE, i x '_ ,r i<,':J LOOSE MOUNTS) VALVE STEM REBUILD(S)
<br /> FLAT REPAIRS) DISMOUNTS) ALLIGATOR CAP(S)
<br /> REPAIR MATERIAL(S)' „- TIRES)BALANCED METAL VALVE CAPS)
<br /> WHEEL,
<br /> ECOr1 LY C1NEO.WHEEL(S) O RING(S)
<br /> PROOLICT INSTALLED
<br /> %,:y.. y. r FINISH MILES:
<br /> I L+ ivl1f SGnI: . . �/ START MILES:
<br /> c TOTAL MILES.
<br /> START TIME: PM
<br /> ON SITE TIME: AM PM
<br /> OUT TIME: AM PM
<br /> FINISH TIME: , ( FM
<br /> LOAD AMOUNT
<br /> :❑,GOVERNM.ENT El LEA EXEMPT EJ OTHER
<br /> — ---°�-- '—' ❑'AGRfCUL:TU.RE'. ❑ COMMON CARRIER/BACK HAUL
<br /> ❑ PICK UP tid Ldly�ya,:eLl/ -,.rt s�M..;r s,� ',(;--;. .,. . 'N,y'fJ.
<br /> d = .,.?
<br /> El `IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS
<br /> ❑ DELIVERY
<br /> EXPaRT" ! j �(,, ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS
<br /> a pato '` 1 ceitify.ihet udder„penalty of..pilrigry,Under thm fawn of the State of California that the information providad above Is Rua and sanest.in addition,t
<br /> e� pr am aware Aha t falsificatiaof chis)Atgqrrmfnation,may result in CTvil penallWs up to$25,+70D per day,per vtoletlon or adminletrative penalties up to
<br /> 11016 on iksaid964bed InrR446)Rseetirces Code section 42962.
<br /> �,' r •,i �FI-li,�YS'���1'?', ,a#,J,'�. ?ti tfr�'".��'�31 M �IS+” ;a`:��!�:f� P����7 - ...
<br /> CUSTOMER PRINT;NAl1AJ: CUSTOMER SIGNATURE DATE
<br /> FSR No.f1igq-17"'v
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