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VVILSO'iiiv NAY 77RE CO., INC. FLEET SERVICE RECORD <br /> U.S. rr�E sQL�s i-�lp <br /> � TPID 10008s7 1 4636 <br /> #01 Wilson Way Tire Wilson Way Tire P,ecap #02 Connell Tire ��Cd221 N. Wilson Wa 1535 Market St. U923 US Tire Sales #24 US Tire Sales <br /> Way 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 <br /> 209.465-0281 209-465-3261 209-466.2581 Hayward, 82 94545 Sacramento,CA 958 <br /> 209-571-5611 510-887-1282 916-395-22d5 <br /> C 1STOMER o O # <br /> DATE •':' <br /> PHONE VEHICLE# <br /> LICENSE R <br /> LOCATION O'r SERVICE �� STATE <br /> I /�- ZIP COD <br /> Eresult <br /> TPID 3h/}/ I� DEC6.L 11 !z� <br /> der penalty f perjury under�e� I� �� <br /> laws of the State of California that the information provided above is true and correct.In addition,lam aware that falsification of <br /> It <br /> n 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 /> enalties up to S25.000 per day,per violation of administrative penalties up to$5,000er violatio <br /> P day <br /> DRIVER NAME DRIVER SIGN as described in Public Resources Code section 42962. <br /> " <br /> MAKE TRUCKlTRAILER LICENSE <br /> STATE ODOMETERIHUB <br /> SPECIAL INSTRUCTIONS {` _ ON <br /> OFF <br /> �tv DcS,Cpinnnni Oc WORK COMPLETE0, QTY DESCRIPTION Or WORK COMPLETED <br /> QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNTS)ON VEHICLE BRASS VALVE STEMS) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNTS) 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 R1NG(S) <br /> yes <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> s START MILES: <br /> J <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> I FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> f GOVERNMENT ®LEA EXEMPT ID OTHER <br /> -- <br /> AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ICK U P LOAD TYPE <br /> IMPORT FROM _ <br /> SLIVERY ❑WHOLE TIRE COUNT WEIGHT IN POUNDS <br /> ] EXPORT TO �r" <br /> VOLUME CUBIC YARDS WEIGHT IN TONS <br /> ��Daro I certify that under penalty of perjury under the laws of the Sta of California that the information provided above is true and correct.In addition, <br /> aor �v am aware that falsification of this information may result civil penalties up $25,000 per day, per violation or administrative penalties up t <br /> � 85,000 perviolation perday as described in Public Resources Code section 42962. <br /> I <br /> • CUSTOMER PRINT NAME CUSTOMER SIGNATURE <br /> DATE <br /> FSRNO. '184636 PLEASE CIRCLE STORE LOCATION AT TOP <br />