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a VVIL S01v WAY TRE CO., � C,. FLEET SERVICE RECORD <br /> —� U.S. TIRE SALES <br /> S j_0 7 PID 1000837. <br /> 184634 <br /> W1 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 Us Tire Sales 924 US Tire Sales <br /> 221 N. Wilson Way 1535 Market St. 2211 N-Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd, <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton, CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 958231 <br /> 209-465-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916.395-2245 <br /> CUSTOMER <br /> P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE' <br /> CUSTOMER TPIDI Za 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 of administrative penalties up to S5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SIGNATU DATE <br /> CUSTOMER •' • <br /> MAKE TRUCKrTRAILER# R� LICENSE7,, ,, STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> ;1Ty DESCRIPTION OF WORM,COMPLETED QTY DESCRIPT70MOF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> r 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 REBUILDS) <br /> FLAT REPAIRS) 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 /> ..©eTALLIED <br /> OT1: SIZE tv1EG DESCR/PT701V FINISH MILES: <br /> START MILES: <br /> r TOTAL MILES: <br /> I <br /> STARTTIME:,g.&! _ <br /> ON SITE TIME: A pl <br /> -- OUT TIME: A `J <br /> FINISH TIME: AM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> l Q GOVERNMENT Q LEA EXEMPT Q OTHER <br /> — } Q AGRICULTURE Q COMMON CARRIER/BACK HAUL j <br /> PICK UP / LOAD TYPE <br /> IMPORT FRO C <br /> ❑DELIVERY Q WHOLE TIRE COUNT Q WEIGHT IN POUNDS <br /> EXPORT TO ✓� Q VOLUME CUBIC YARDS Q WEIGHT IN TONS <br /> yc Dalo 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 <br /> `oo am aware that talsificalion of this information may result in civil penalties up $25,000 per day, per violation or administrative penalties up t <br /> SS,C100 pervioiation perday as described in Public Resources Code section 42962. <br /> d <br /> — m <br /> • <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR N®. 184634 4 PLEASE CIRCLE. STORE LOCATION AT TOP <br />