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rr i WILSON WAY TITRE CO., Ill T rR" FLEET SERVICE RECORD <br /> J.S. TIRE ,SALE'S . � ��� � TPID 1000837 18 4 6 4 2 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell 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 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 95823 <br /> 209-465-0281 209-465-3262 209466-2561 209-571-5611 510-887-12U 916-395-2245 <br /> CUSTOME P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID , / —' QECAL# <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 penial 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$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SIGNATUR DATE <br /> X3�� <br /> CUSTOMER VEHICLE •' <br /> MAKE TRUCK/TRAILER# / LICENSE STATE ODOMETER/HUB <br /> �L 4/L�5 <br /> SPECIAL INSTRUCTIONS ' ON OFF <br /> 4A, ADO sUp� <br /> QTY. DESCRIPTION OF WORK COMPLETED QTy DESCRIPTION OF WORK COUPLETED 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 /> FEAT REP;4dR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> t !t IR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> --O• • <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> l START MILES: GG <br /> TOTAL MILES. <br /> START TIME!0/ j AM( <br /> ON SITE TIME: _ S J� AM 6. <br /> OUTTIME: A vLu AM <br /> FINISH TIME: 41"`?—?W AM P <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> GOVERNMENT Q LEA EXEMPT ❑OTHER <br /> Q AGRICULTURE Q COMMON CARRIERBACK HAUL <br /> PICK UPLOAD TYPE <br /> IMPORT FROM ` ®WHOLE TIRE COUNT <br /> DELIVERY WEIGHT IN POUNDS <br /> Q EXPORT TO ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ,c pato 1 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 /> ob Jr amaware that falslfi600n of this information may result in civil penalties up$25,000 per day, per violation or administrative penalties up.to <br /> $5,000 perviolation per day as described in Public Resources Code section 42962. <br /> w o <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> �.... .. <br /> 4 P1 A (`i A f _ <br />