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WILSON WAY TIRE CO. NT E® FLEE RACE RECORD <br /> U.S. TIRE SALES <br /> tUSrJre <br /> TPID 1 00837. 156766 <br /> O1 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #2Sales #23 U Ire Sales #24 US Tire Sales <br /> 21 N.Wilson Way 1535 Market St. 2211 N.Wilson Way t v 5 National A've. 6530 Franklin Blvd. <br /> tackton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 05-465-0281 209-465-3262 209-466-2581 209471-5611 510-887-1282 916-395-2245 <br /> USTOMER P.O.# DATE <br /> PHONE VEHICLE#�! <br /> LICENSE# <br /> DCATION OF SERVICE- STATE ZIP CODE <br /> •�® <br /> CUSTOMER TPID <br /> � I DECAL# ZZ <br /> I certify that under penalty of perjury under the taws of the State of California that the information provided above is true and correct In addition,I am aware that faisifrcatien 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,par violation of administrative penalties up to$5,000 per violation per day?s described in Public Resources Code section 42962. <br /> RIVER NAME DRIVER SIGNATUREDATE <br /> x -�G-1.0 <br /> CUSTOMER VEHICLE INFORMATICN <br /> AKE TRUCK/TRAILER <br /> tX/� LICENSE STATE ODOMETERIHUB <br /> SPECIAL INSTRUCTIONS ` ON OFF <br /> j C - <br /> r qA�� � n.►�o yAslr'vc <br /> QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL f! MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I 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 /> QTY. SIZE MFG DESCRIPTION FINISH MILES: .. st <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: AN(n <br /> ON SITE TIME: .��\ AMEt <br /> OUTTIME: 4f.*/6 Akl <br /> IF <br /> FINISH TIME: 'VdAta <br /> .OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> LIGOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> — — —— —— ❑AGIRICULTURE Q COMMON CARRIERBACK HAUL <br /> PICK UP ILOAD TYPE <br /> ❑ IMPORT FROM WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ®DELIVERY m <br /> ❑ EXPORT TO V(� t _ VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> pato 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 /> Loi', Tr 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 /> $5,900 perviolation perday as described In Public Resources Code section 42962. <br /> p, o <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 156766 PLEASE CIRCLE STORE LOCATION AT'rco <br />