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® � WILSON WAY TIRE CO,419E . EET SERVICE RECORD <br /> U.S. TIRE SALES/ T� <br /> T 1000837• 180887 <br /> .ftf Wilson Way Tire Wilson Way Trre Recap #02 Connell Tire # 1 US a #23 US rre Sales #24 US Tire Sales <br /> i111 N.Wilson Way 1535 Market St. 2211 N.Wilson Wa 2600 Yosemite Blvd. 1915 N 'anal Ave. 6530 Franklin Blvd. <br /> Stockton, CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Wayw d,CA 94545 Sacramento,6A 95823 <br /> 209-465-0281 Q 209-465-3262 209-466-2581 209.571-5611 51 7-1282 916-395-2245 <br /> ::USTOMER - P.0 P.O. DATE <br /> _ 5:31Q t6 <br /> PHONE VEHICLE# <br /> 1aa00-1 <br /> LICENSE# <br /> .00ATION OF SERVICE STATE ZIP CODE <br /> / -- r-- <br /> CUSTOMER TPID <br /> I Q <br /> 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 <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$5,000 per violation p d as described in Public Resources Code section 42962. <br /> )RIVER NAME DRIVER SIGNAT DATEam <br /> X '✓o��`O <br /> CUSTOMERA/EkICLEAFORMAT• <br /> RAKE TRUCKITRAILER# `' 110 Asr LICENSE STATE ODOMETERIHUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED OTY 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 i LOOSE MOUNT(S) VALVE STEM RESUILD(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 /> AR(50UCTINSTA7• <br /> QTY SIZE MPG DESCRIPTION FINISH MILES: <br /> START MILES: Z <br /> TOTAL MILES: <br /> STARTTIME:_�T Q PM <br /> ON SITE TIME:T,Z4TJ PM <br /> OUT TIME:I AM <br /> FINISH TIME:igk!�5— _'Mo <br /> _OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> l�GOVERNMENT ElLEA EXEMPT J OTHER <br /> •— ❑AGRICULTURE [-j COMMON CARRIER/BACK HAUL <br /> '6ICK UP ALOA TYPE <br /> ❑ IMPORT FROM 4jrWHOLE TIRE COUNT. EJ WEIGHT IN POUNDS <br /> 'DELIVERY <br /> ❑ EXPORT TO l i ❑VOLUME CUBIC A S ❑WEIGHT IN TONS <br /> �oc�c Dula Trc I prtify that under penalty of perj ry under the laws of the State of California th the infor t rovided above is true and correct.In addition,I <br /> am re that falsification of this information may result in dull penalties u 25,000 or vi ation or administrative penalties up to <br /> t, 00 prer of tion per day scribed in Public Resources Code section 4 96 <br /> ...- C� <br /> • <br /> p -TOMER PRINT AME CUSTO E DATE <br /> FSR O C3 F'LE-,.� : Ir'," t:. - L• '�rA- ;oil A.T C}? <br />