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WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837 14 7 5 4 b <br /> #01 Wilson Way Tire Wilson Way Tire Recap 902 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 209-466-2581 209-571-5611 <br /> 209-465-326,2 510.887-1282 916-395-2245. <br /> CUSTOMER F P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE i STATE ZIP CODE <br /> CUSTOMER TPID DECAL# 9; <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 /> DRIVERNAME DRIVr SIG qATURE DATE <br /> x <br /> —51"Xi <br /> .5 <br /> I M-11 <br /> ,MAKE TRUGI<fTRAILER 4 LICENSF STATE ODOMETER/HUB <br /> 4P3 <br /> SPECIAL INSTRUCTIONS ON <br /> PiJP TED -SCP <br /> OF WORK COM ETE�D E RIPTION OF WORK COMPLETED ,62 <br /> _T P PLL QTY <br /> CERVICtBRASS VALVE STEM(S) <br /> MOUNT/DISMOUNT(S)ON VEHICLE <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> ------------ <br /> AIRSERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FIJAT REPAIR LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED -_METAL VALVE CAP(S)2 <br /> WHEEL SWITCH(S) <br /> RECONDITIONED WHEEL(S) 0 RiOM Ta <br /> A ELMM'Em -FALLEQ�� <br /> FINISH MILES: <br /> –.,QTY SIZE= <br /> START MILES: <br /> TOTAL MILES. <br /> START TIME: AM <br /> ON SITE TIME: AM PM <br /> .OUT TIME; AM PM <br /> .,FINISH TIME: A M Pini) <br /> LOAD AMOUNT ------- <br /> AULER ExE� IFAPPLICABLE <br /> --------- <br /> LJ GOVERNMENT [I LEA EXEMPT LJ OTHER <br /> U AGRICULTURE U COMMON CARRIER/BACK HAUL <br /> Q PICK UP LOAD TYPE <br /> [3IMPORT FROM---------- - E)WHOLE TIRE COUNT (a WEIGHT IN POUNDS <br /> Q DELIVERY <br /> Q EXPORTTO E)VOLUME CUBIC YARDS OWEIGHT INTONS <br /> '�Ncl Datq I certify that under penalty of perjury under the laws of the State ofCalifomla that the Information provided above is true and correct.In addition I <br /> 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 /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR NO. 14T546, <br />