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Apr, 24, 2008 2:43PM C HELL TIRE/GOLDEN STATE TRUCK No- 6481 P. 2 <br /> WILSOAWAY TIRE MY INC. FLEET SERVICE RECORD <br /> U.S. T FS TPID 1000817. 109646 <br /> eat Wilson Way Tiro Wilson Way Tin Reaalo. eo2 n rlre #05 Wlleon Way Tire e91 us rive Sates da9 us nm Sales /24 Us Tfre rates <br /> 271 N.W9sen Way 1595 Ma of St. 221 n Wiry t 197 W.Elevanth St: aw Voaer»ffe Blvd. f 915 Hatkna1 Ave• 6390 rmitklln Rfvd. <br /> Sfackf&4 Co.06'205 Stockton,Ca.96295 S on,Co.95"S� Tracy,Co.93376- Modesto,CA.96954 HA'V~,Co.94344 Sacrurnanfo,GA.88823 <br /> 809465-0291 208495-726.2 2591 2WOS-4087 209d71.99f! 910.887--1389 9t6�s 224e <br /> CUSTOMER P.O.# DATE APPI <br /> PHONE VEHICLE# <br /> LICENSE#W00 <br /> -�'J <br /> LOCATION OF SERVICE S7ATE, -�f r+— �ZIP CODE <br /> �'� c/ <br /> CUSTOMER TPID <br /> I cortify that under penalty of perjury under the lawa of the State of CAllfornla 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 Hoular 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$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME V DIVER SIGNATURE DATE <br /> MAKE TUC AILER#, LICENSE STATE ODOMETER/HUB <br /> �S„}'.o',t:)a F. t.1 .Ivi. bbF'. . .:. ' ..V '5..••, ■ 4Hkt:'4J"�,`5.:....4f 1,.-i:• n�,-P!y/;A7.:i/xnqr `t �> LiQyaAWS :110z;” <br /> Yi7 Mr..G,E?,•u,�.�jnt%t..K'v� i(i•if'6�.4Jrr` i ]� <br /> ":.. ..: .. ..Wf <br /> 7Y; ;'^u9 F7jp t lU;t7F,WC}Rk G[f i�l L3"<. `;:t iY: f-� CRIF� i�;WditKr oMp�°Er�bm 'b 1IONrOO'M."!pO,MPi <br /> IC L MO 1 DI NT(S)ON V LE�' BRASS VALVE ST£M(S) <br /> FLEET INSPECTION MOUNT/DI$MOLfNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD($) <br /> FLAT REPAIR(5) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATEfiIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RINd(S) <br /> a• ix i > f:.'< p?' rryy <,M• .i, FINISH MILES: <br /> START MILES:-7—A—,— <br /> TOTAL <br /> ILESTOTAL MILES: <br /> START TIME: 6V FM <br /> ON SITE TIME: AM FM <br /> OUT TIME: AM PM <br /> r' <br /> FINISH TIME: M M <br /> LOAD AMOUNT " r, .I `:fyMW lbhl. Fy�1iP"'IA'[� .r�n;k J•s;,;,,- <br /> -- , <br /> ❑ GOVERNMENT . . El LEA EXEMPT [I OTHER <br /> -- ❑AGRICULTURE , ❑ COMMON CARRIER/BACK HAUL <br /> '6crtlCK UP L��ktl'�A�';.,r�. <br /> b IMPORT FROM . LE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> El DELIVERY <br /> XPORT TO ❑VOLUME CUBIC YARDS{•' ❑ WEIGHT IN TONS <br /> Uofa I cortity that under ppenalty of p .jury under the laws of the$tat*of C4hfornid that III*intorm4tlon provided above is true and correct.In addition,I <br /> am aware that falslflcation of this Information may result n clvll peneltlea up to 12S,000 per day,per violation or administrativ$pen Rias up to <br /> Q� 35,000 per violation per day As described in Publie Rate o Cede seelten 42962. <br /> .COSTOfu(LR PgINT,NAME STOMER SIGNATU E DATE T <br /> FSR No. 10 q G 4`8 <br />