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ED*d «E T S02 Er_ EEE 90:S T 9000-bE-E3d <br /> WILSON WA TIRE CO., INC. l i _EET SERVICE RECORD <br /> U.S. TIRE SALES . TpIp 1000837, 810 5 8 <br /> w;(eo.1 Way Tira Aoean lia2 Connell Tira AGS Wilson Way The +27 us rfre Saba r�7 us 1Trr Sa7oa y�L1S Tlra sol.9 <br /> O!W,6—way Ti— Y <br /> 21 N.Wilson way IMS market SI. 2211 N.Wltson Way 11?J W.E/orwftn St. :Goo yox_ite alvd. v915 National Ave. 6330 FrArdrlin Blvd. <br /> IlotJclan,rid.9CiZOa a70Glt tOnlr Ge.9J245 itocRfwr.Cd.Bwnoi T.acyr Oa 9x76 nuoo.r.rq CA.9036- lt+W/d.G—041;+10 ye/an1a11fD.C.A.95127 <br /> 1on•aeso�l 209.169-9462 209 o6G zser soaBss ooaT ro9S7r GCt/ s/aaoy.lzez �,sa9s z�oG <br /> CUSTOMEFI p.0. tt GATE 1\4;::R ! <br /> Ile <br /> PHONE VEHICLE>: fe <br /> LICENSE x <br /> LOCATION!OF SERVICE STATE �/J ZiP CODE <br /> a true DECAL« L addition,' I a>s I aware, hat CUSTOMER TPID L_�1� <br /> Jr1©LV � ' <br /> 1 certify that under penalty of perjury under the laws of the State oT Ganrornla that the iolotrnnuon prodded ibovohlsiFlcatlon of <br /> Tnla Int-011—may reautt In auaprrn..on,revocmton.o.d.niyl 01 ranawai of the Warts The Hanlar F6-aiar3tiOn DureUant to Public RBSOUTCCS Code section 42960 and may <br /> recut;in civil penalties up to 525,000 per day,per violation or administrative penalties up to 35,000 per vlolmion per day as described In Public RC60urce3 C006 section aZ9e2. <br /> DRIVER NAME DRIVER SIGNATURE DATE <br /> MAKE TRUCKli RAILER is /1 r�� LIUENSE y� �v TATE,;n ODOPvtETEWHUL' <br /> SPECIAL INSTRUCTIONS 1 ON OFF <br /> QTY, ON OF WOPK C044 Lk: QTY. 4., Or',SPLE7ED QTY, DESCRIPTIOnr O)r WORK CG'MFLETED <br /> SERVICE ra m0UHT I DISMOUNT(S)Ort VEHI"I BRASS VALVE STENI(S) <br /> FLEET INSPECTION MOUNT i D*MGUNT(S)L005E ALUMINUM STEO(S) <br /> AIR SERVICE LOOSE MOUNTS) VALVE STENI REBUILD(S) <br /> FLAT HEPAIR(S) LOOSE DISMOUNT{S) ALLIGATOR CAP(S) <br /> REPAIR PAATER!AL(S1 TIRE(SI BALANCED METAL VALVE CAPS) <br /> WHEEL SVVITCI-(S) RECONDITIONED WHEELIE) 0 RING(S) <br /> OTY. %SIZE MFG DESCRIPT)Oid FINISH MILES. <br /> START NILESi <br /> TOTAL MILE <br /> S"AFiT TI VIE; fa <br /> ON SITE TIME. Ata cnr <br /> OUT TINiE• AY Prl <br /> �Jw <br /> hr Q ;:INGHTIME._.�� B� Ata PM <br /> LOAD AMOUNT HAULE19 tX&WON IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> ----- ' [] AGRICULTURE ❑ COMMON CARRIEFI/B•ACK HAUL <br /> D PICKUP LOAD TYPE <br /> ❑ IMPORT FP.OM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ❑ DELIVERY ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> O EXPORT TO <br /> II."- p r_ r�; _.certify that under penatty of perlury under the lawn of tnu S:ote of Caldornia that the information provided above is true and eonect.In addlrgn,I <br /> �s baro =� SM aware that t3t31tication of thlS tnrorm3tlon may result in civil penaltles up io 525,000 per day,per violation or administrative penalties up to <br /> $5,000 per violation per day as descnbca in Public Resources Code section 02962. <br /> S <br /> 0 <br /> w <br /> CUSTOMER PRINT NAME _ CUSTOMER SIGNATURE DATE <br /> 'G ST 9riri b� Q�� iSO�'-:bc-EIGc:r>;� 'obi ;JTi Flp�r� Uosl ISI <br />