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WILSON WAS' TIRE CO., WC. FLEET s��vcc� R�ca�� <br /> U.S. TIFF SALES � <br /> _;. TPID `i000837• �4-4���'w'�2 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales 3 <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 j <br /> 209465-0281 5209-465-3262 209466.2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# v V <br /> LICENSE# <br /> _ } <br /> LOCATION OF SERVICEf STATE Zi CODE a <br /> o "Al <br /> _ .,.I.... r-:.• is 7- <br /> CUSTOMER TPID I—,(� DECAL# 5�q- 6 � `? : <br /> I certify that undgr penalty of perjury under the laws ofthe State-,off•California that the Information provided above is true and correct.I"n"addition,I am aware tl4att(falsification of <br /> this <br /> m <br /> 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 penaltles 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 r DRIVERS GNATURE DATE <br /> MAKE :F t (^ TRUCK/TRAILER LICENSE STATE Z/ ,ODOMETERMUB <br /> I 1 _ <br /> r <br /> SPECIAL INSTRUCTIONS- -" " <br /> �• � ..:�r._�:,;.. .,.:: � ON I OFF- <br /> QTY, <br /> FFQT ; DESCRIPTION QF WORK COASPLETED QTY. D€SCRIPTIOi^J OF WORK COTrPLCTED RIPTIOPJ OF WORK_COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICL rpMSS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(5)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) TIRES}BALANCED METAL VALVE CAP(S) j <br /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> SIZE,' MFG i i " _ f)ES,t RIPTlON FINISH MILES: <br /> - / a.^' <br /> -Oo rte}/ J� , 0-' pti START MILES: <br /> TOTAL MILES { `) <br /> START TIME <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: +1 AM,PM <br /> LOAD AMOUNT -- -- HAULER EXEMPTION IF>I?�PPLIGr36LE' <br /> i ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> CjAGRICULTURE ❑COMMON CARRIERIBACK HAUL <br /> PICKUP �� � � LOAD TYPE <br /> \ 0 IMPORT FROM WHOLE TIRE COUNT (3 WEIGHT IN POUNDS <br /> ❑DELIVERY l <br /> d-WXPORTTO,72 t j r `� p VOLUME CUBIC YARDS WEIGHT IN TANS <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 additlon,l; <br /> 006 poroTo am aware that falsification of this Information may result in civil penalties up$25,000 per day,per violation or administrative penalties up1b:`s'.'^.; <br /> N $5,000 per violation per day astdescribed In Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE ] <br /> FSR No, IA,7421, :� <br />