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----------------- - _...............- <br /> t r r WILSON WAY TIRE C ., I ����� FL T SERVICE RECORD <br /> U.S. TIRE SAL ID 1000837. 172418 <br /> 01 Wilson Way Tire Wilson Way Tire Recap #02 Connell T #21 US Tire Sales #23 US Tire Sales #24 US Tiro Sales <br /> 21 N.Wifson Way 1535 Market St. 2211 N. <br /> Wits <br /> Way 2600 Yosemite Blvd. 1915 Na}ional Ave. 6530 Franklin Blv <br /> tockton, CA 95205 Stockton,CA 95205 Stockton,CA 9 05 Modesto,CA Hayward,CA 94545 Sacramento,CA 9 23 <br /> 09-465-0281 209-465-3262 209-466-2561 11 510-887-1282 916.395.2245 a li <br /> US70MER ^ P.O-# DATE _ r <br /> 1- <br /> PHONE VEHICLE# <br /> LICENSE# <br /> )CATION OF SERVICEasp STATE ZIP CODE� <br /> CUSTOMER TPI) D <br /> �— 3=1 ��;_I I v — <br /> � I ECAL# j <br /> (, J <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 renevral of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42950 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 /> is <br /> RIVER NAME DRIVER SIGNATURE DATE <br /> X -{ -l 6 <br /> CUSTOMER •' • <br /> AKE TRUCKtWALa�# [ , LICENSE STATE ODOMETER/HUB <br /> Ll V)— <br /> SPECIAL INSTRUCTIONS ' ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED 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 /> 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 RING(S) <br /> PRODD <br /> QTY SIZE MFG DESCRIPTION FINISH MILES <br /> o 6 c START MILES: <br /> TOTAL MILES: <br /> START TIME: 1fS� ��AM <br /> ON SITE TIME: sem+ AM <br /> OUT TIME:—3 Q!9 —A PM <br /> FINISH TIME: AM PM <br /> OAD AMOUNT HAULER EXEMPTION IF APPLICABLE_ <br /> _ — • ©GOVERNMENT 0 LEA EXEMPT Q OTHER <br /> AGRICULTURE I] COMMON CARRIER/BACK HAUL <br /> PICK UPLOAalYPE <br /> Q IMPORT FROMIlle." <br /> WHOLE TIRE COUNT <br /> ] DELIVERY - WEIGHT IN POUNDS <br /> Q EXPORT TO ❑VOLUME CUBIC YARDS D WEIGHT IN TONS <br /> polo 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 /> am Aware that falsification of this information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> ` $5,000 per violation per day as described in Public Resources Code section 42962 <br /> A, I <br /> tto <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> 7SR. No, 172418 PLEASE CIRCLE S T ORI= LGC; 7' <br />