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t e WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES �� TPID 1000837• 18 Q 11 <br /> Wilson Wy Tire Wilson Way Tire Recap #02 Connell Tire 921 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 11 N.W!lson'Way 1335 Market St. 2211 N.Wilson Way 2600 Yo mi 1915 Nationahgve. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Hayward,CA 94545 Sacramento,CA 95813 <br /> 209-465-0281 209465-3262 209=466-2587 209- 5611 570-8H7-1282 916.395-2245 <br /> USTOMER fs P.O.# 6ATE l� + <br /> PHONE V HICLE# <br /> CENSE# <br /> �7 <br /> OCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID l I �— DECAL# <br /> . 4 -� ► i 7; ,CII _ !a 3.7_ <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 falsificationof <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 S25,000 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 DRIVER SIGNAT DATE <br /> X S—.3?— 6 <br /> MAKE TRUCK/TRAILER# b }-� LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> eVL�.�,.� <br /> _---_.-. ----- ---- --..... <br /> _ ------ ---- --- ------- <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL 2 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 /> PO <br /> QTYI SIZE MFG DESCRIPTION FINISH MILES: <br /> �D S`FART MILES: <br /> TOTAL MILES. <br /> STARTTIME d Ai Ol PM <br /> ON SITE TIME: 1d !t PM <br /> OUT TIME: 1/ �� n PM <br /> FINISH TIME: <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT CILEA EXEMPT ® OTHER <br /> ®AGRICULTURE J COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> © IMPORT FROM/Z� HOLE TIRE COUNT ®WEIGHT IN POUNDS <br /> CJ DELIVERY <br /> ❑ EXPORT TO L-3 VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> `c Hato I hertify 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 /> 0o 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 /> P SSt000 pervialation per day as described in Public Resources Code section 42952. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR NO. 180895 CRC' E S;01r-r)r 01f.ATION' v- TOR <br />