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r. WILSON WAY TIRE CO., I EET SERVICE RECORD <br /> U.S. TIRE SALES <br /> - 3 <br /> T ID 1000837. 18 4 8 5 5 <br /> #01 Wilson Way Tire Wilson Way Tire Recap 902 Connell Tire #21 US Tire Sales 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 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209.465-0281 209-465-3262 209466-2581 611 510-887-1282, 916-395-2245 <br /> CUSTOMERP.O.# DATE <br /> L-/!✓�' j PHONE VEHICLE# <br /> Its 1 f UUdS CJ <br /> LICENSE# <br /> LOCATION OF:SERVICE-_„ ,�,.. __�___._ . . �� STATE ZIP CODE <br /> � i-; <br /> s0 <br /> CUSTOMER TPID i — h <br /> 1 / <br /> I ' � d' ! 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.to 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$25,000 per day,per violation of administrative penalties up to S5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME R R SIGNATURE DATE <br /> CUSTOMER VEHICLE INPORiMATIONI <br /> MA TRUCKTRAILER$r— LICENSE STATE ODOMETERIHUB <br /> J) <br /> SPECIAL INSTRUCT! ON OFF <br /> i <br /> QTY <br /> DE4' OFWORK C MPLETED QTY. DESCRIPTION OF MPL QTY DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL OLINT!DISMOUNT(S)ON VEHICL i � 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) 0 RING(S) <br /> PRODUCT <br /> OTY SIZE MFG DESCRIPPON FINISH MILES: <br /> 9 5— 7 C6 5 P ;z 9: 3 161 l START MILES: <br /> Z 3 -33 ! TOTAI.MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: f < AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑ LEA EXEMPT ❑OTHER <br /> LJ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> �-PtCK <br /> UPLOAD TYPE <br /> ❑ IMPORTFROM__ <br /> 0 DELIVERY [HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑`E9C�ORT TO SY3 1 lVOLUME CUBIC YARDS I'-]WEIGHT IN TONS <br /> \c pgaq _ Iicertify 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 /> `ot rr am aware that falsification of this information may result in civil penalties up 525,000 per day, pets, violation or administrative penalties to <br /> u •000per violation per day asdescribed inPublicResources Codese ' n42962. / <br /> "I,C"' -r-� <br /> CUSTOMER PRINT NAME -- STO ,S NATU DA <br /> FSR NO. 1840055 PLEASE CIRCLE STORE LOCATION .AT TOP <br />