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I��P, , ,• WILSO&WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> 10TIRE SALES to <br /> TPID 1000837• ,._ 1,"3 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID — i i DECAL# j <br /> 1 - <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 per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •' ' • <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY , DESCRIPTION OF WORK COMPLETED QTY, 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 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 RINGS) <br /> PRODUCT <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> STARTTIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑ LEA EXEMPT ❑OTHER <br /> - ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> ❑ IMPORT FROM - [-:WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY <br /> ❑ EXPORT TO ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <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 <br /> `or�c Dato T'v 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 /> $5,000 per violation per day as described in Public Resources Code section 42962. <br /> m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE 'I' <br /> FSR No. �. E- <br />