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WIL.S® <br /> Ir N WAY TIRE C®., INC �/�l� ET SERVICE RECORD <br /> U.s, TIRE SALES ID 1, 00837. 15 6 7 7 6 <br /> #0121 N. <br /> Wilslsonon <br /> Way Tile Wilson Way-TireRomp #02 Gonne!!Tire #21 US The es #23 US Tire ales <br /> 221 N.Wilson Way 1535 Market Sf. 2211 N.Wilson Way #24 US Tire Safes <br /> Stockton,CA 95205 Brockton,CA 95205 2600 Yosemite 191S Natio al Ave. 6530 Franklin Blvd. <br /> Stockton;CA 95205 Modesto,CA 95354 <br /> 209-465-0281 209-465-3262 209 466-2581 Hayward A 94545 Sacramento,CA 95823 _ <br /> 209-571-5611 •1282 916-395-2245 <br /> CUSTOMER P.D.# DATE <br /> S-7-1`6. <br /> PHONE VEHICLE# <br /> so <br /> LICENSE# <br /> LOCATION OF SERVICE <br /> STATE ZIP CODE <br /> CUSTOMER TPID ` <br /> L i��_f r Ii j J 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 In addition,I am aware that falsification of i <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Ttre 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 <br /> DRIVER SIGNATURE <br /> �yJs DATE <br /> ^ <br /> _ 3-7— <br /> MAKE <br /> 7—M 4KE TRUCKITRAILER# • • <br /> `Yds� � LICENSE(/�Q®/� STATE G Q ODOMETER/HUB <br /> lien <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> QTY DESCRIPTION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED <br /> QTY. DESCRfPTlON OF WORK COMPLETEDSERVICE 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) <br /> TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> TALLED <br /> SIZE MFG DESCRIPTION FINISH MILES:C-Pvea <br /> START MILES• <br /> TOTAL MILES: <br /> STARTTIME:T�AM <br /> ON SITE TIME�2 ' AM FM� <br /> OUT TIME: �- r.it eoj AM Pb <br /> FINISH TIME: AM <br /> .OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑ LEA EXEMPT, Q OTHER <br /> • I]AGRICULTURE <br /> :1 COMMON CARRIER/BACK HAUL <br /> &PICK UP ! LOAD TYPE <br /> II IMPORT FROM ( L ' <br /> DELIVERY ZWHOLE TIRE COUNT ®WEIGHT IN POUNDS <br /> (] EXPORT TO <br /> !. (ti O VOLUME CUE 0C YAWS ®WEIGHT IN TONS <br /> on��DtrIQ J I cirtify that under penalty of perjury under the laws of the State of California that the inforVro above is true and correct.In addition,1 <br /> ware that falsification of this information may result in civil penalties uP $25,000 ption or administrative penalties up to <br /> DO per violation per day asdescribe" PublicReso rcesCodesection42962. <br /> s <br /> C TOMER PRI 4T NA E COST MER S <br /> DATE <br /> -SR No. 7 p LJ'7 CT <br /> 1�6 pLCldc,1= <br />