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O T 'd ",BE T 502- c:t'_7 60E 90:S T 900E-t'c-1336 <br /> WILSON .' TIRE CO-, INC_ LEFT SERVICE RECORD <br /> U.S. TIRE SALES R <br /> TP I D 1000837. 80264 <br /> - <br /> XIo-X ii4t Way 1Zro WiA9on Way Toe Recap F022 Ca77Mate"J7 1`03 1v"=n Way Trre 121 VS Tar ^• <br /> re Saes TJ u3'JYte SWm 72#V5 ce <br /> TWO Sha <br /> T�=1 If.t•YI/Yprl Way f 536 Nivkot SL =If H.7trtban Way 17 39 W.E7a.errth Sf. ]fr00 Yoeomiie BIv0. 7915 Ptltipn07 P.o. HSJO Franklin Nlvd. <br /> e9o-e4f—Ca.1162.06 atoorhtevt.Ca ir-"c Stoc4t—C-0520S T-ey,C.►05-1-6 almdocla,Cd.9.57.E "atr..•_4 Com.04545 S'rc--tet,Gb 96523 <br /> ZOD+165.OT81 209�4.SJZ62 109.r6Yr1501 Z091r3Sa08T 209.3T1.56JJ 310&nT•r282 916�B,SZ.7a3 <br /> CUSTOMER P.O. tt DAT <br /> PHONE VEHICLE 4 <br /> - LICENSE <br /> LOCAT J F S JCE - STATE �D� <br /> CUSTOMER TPID 0\ Q V DECAL# —� <br /> I ctrUty 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 talsification of <br /> This Information may result in suspension•revocation,or denial of renewal all the Waste Tire Hauler Registration pursuant to Publir:Aaeources Code section 42960 and may <br /> moult in clvll penalties up er.942ifop per any,per,violation or odminlotrativc penalties up to 13,000 per violation per day am Cmcrlaed In Pub"o ROaoureea Code aeetlon 42062. <br /> DRIVER NAME ,Pzc� vDRIV URE DATE <br /> X � r `d <br /> CUSTOMER VEHICLE INFORMATION <br /> MAK T Rh11,ER r LICENSE STATE ODOMETERIHUB <br /> Y <br /> SPECIAL INSTRUCTIONS ON OFF <br /> 1 -_ ._..._. __ .._..- -- -- -- PRPP- --__.__._._._._....-- --...--•PRPP-- <br /> O.TY<,r DN OF WORK COMPLETED QTY OFc 'K COMP ETED O7Y DESCRIPTION OF WORK COMPLETED <br /> SERVICE 1L ^ VEHICLE ERASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT r DISMOUNT(S) LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIRS) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIALS) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH+,S) RECONDITIONED WHEELS) O RING(S) <br /> PRODUCT INSrALLED <br /> QTY3 SIZE MFG DESCFIPTION FINISH MILES <br /> C.. r - 19 I ZLQ °74RT MILEg <br /> TOTAL MILES.;A <br /> START TIME: { gra <br /> ON SITE TIME: ' 0A Pre <br /> OUT TIME: �'•' �� <br /> r <br /> FINISH TWE, <br /> LOAD AMOLINCE HAULER EXEMPTION IF APPLICABLE <br /> GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> --- -- ❑ AGRICULTURE ❑ COMMON CARR IEWBACK HAUL" <br /> PICK UP r OAD TYPE <br /> IMPORT FROPA f WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS ~ <br /> (r� DE (VERY <br /> ( EXPORT TO yl J (r ❑ VOLUME C BIC YA S C WE]G 7!IN TONS <br /> I-eertiry that under penalty of perjury under the lava of the State of California at the informal* n provided above Ie rue bnd correct.In addition.I <br /> o�c DQry am a-;Am that falsification of this information may result in civil penaltiea u0 0$25,000 per y,per violation or a int tive penalties up to <br /> s aM 55.000 per violation per day as described In Public Resources Code scct"io aZ9fi2. <br /> CUSTOMER PRINT NAME CUSTOMS TU E DATE <br /> N. <br /> FSR No. R n 2 Ra. - - ----- ---- <br /> GT °d C)T:ST 900; G� 4d' TSU9-�t -60c:xrJ� 'OD d.1 T j P1112FI UOS I l fry <br />