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WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837. 14 5141 <br /> #01 Wilson Way Tire Wilson Way Tire Recap 902 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Safes <br /> 221 N.Wilson Way 1535 Market St. 2211 M Wilson Way 2600 Yosemite Blvd. 1915 NaUonalAve. 5530 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 209-466-2561 209-571-5611 510.887.1282 916.395.2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE Z-0 Y^ JA) a1z )16 4r r/. STATE ca TIP CODE <br /> CUSTOMER TPID - DECAL# Q <br /> i <br /> 1 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 AiIJRE DATE <br /> CUSTOMER • <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ` ON OFF <br /> i <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY -DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE S' BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE r 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 WHEELS) 0 RING(S) <br /> PRODUCT INSTALLED <br /> QMFG DES IPTlON FINISH MILES: <br /> TY SIZE <br /> to 7/ \ START MILES: <br /> � V <br /> TOTAL MILES: <br /> START TIME:_ <br /> ON SITE TIME: `AM PM <br /> OUT TIME AM PM <br /> FINISH TIME: o_- A PM <br /> LAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> --- -- ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER _ <br /> ❑AGRICULTURE LJ COMMON CARRIER/BACK HAUL <br /> [ 'PICK UP LOAD TYPE <br /> ❑ IMPORT FROM t JNHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY f , <br /> EXPORTTO /> ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> e Data I certify that under penalty of perjury under tho laws of the State of California that the information provided above Is true and correct.In addition,I <br /> .0 1, 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 /> �° rej $S,OQOperviolation per day asdescribed lnPublic Resourrxs desection 42 62. <br /> bUSTOMER PRINT NAME US ER IGNATURE DATE <br /> FSR No. 145141 PLEASE CIRCLE STORE LOCATION AT TOP <br />