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LID'd 4,GH T SOL EVE 601. GQ:S T <br /> ° <br /> ZX 541 1. E f <br /> WILSON WAY TIRE CO., IN9. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837- 80103 <br /> 001 W;1—Way Tiro Wilton Way T1.v Rcaap 402 C--V Ti— •"0.5 Wllaon"Tire psi u5 7,—Saba 1023 us 72M Saloa 024 US Tiro A,roa <br /> 231 N.Wrl9 Way 7575 MMPUO(St, 2211 N.Wilson Way 1133 W.Dowenth St. 2600 Yosorrrira Blvd. 1915 M9tlonW AyO. 6530 ironrlin Blvd. <br /> Ctoc.rton Ca.0620A 8oeo—,C—'a-� a*oc�wn,6a.9:305 Tracy,C.93776 GN D375r May»-.,....,G_.?rbb 8aoromc+rro,".lda7. <br /> X08-6r.S0?Bt 209-.t6YJ..61 ZOB.a6Y.a6o1 209.e36-4097 20P57f.56se 6yp.tsR7.110.8 9fB39s:31S <br /> CUSTOMER <br /> PO.# DATE <br /> PHONE VEHICLE <br /> LICENSE# <br /> LOCATI OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID I I � �V —�1 � I DECAL N LQ1�1-'���� <br /> 1 certify that under penalty of perjury under the laws of the State of Catlfdrnla that tho Information provided above Is true ane correct.In addition,l am aware that falsification of <br /> this information may result in suspension, revocation,or denial of renewal of the waste Tire Hauler Regimrauon pursuant to Public Resources Code section 429h0 and may <br /> result In cfvri penaries up to 525.000 per day,per violation or administrative penalties up to 55,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAMEDRIVE CI UR DATE _ <br /> X <br /> CUSTOMER VEHIli INFORMATION <br /> MAKE TRUCK/TRAILER k LICENSE TATE ODOMETER/HUB <br /> Y 507- l? _ C71. <br /> SPECIAL INSTRUCTIONS Cf": CFF <br /> Ti <br /> 1 � r <br /> OTY DESCAIP77ON OF WORK COMPLETED QTY DESCRIP ' QMETED OTy DESCRIPRON OF WORK COMPLETED <br /> °ERVICE C foiOUN !0ISMOUNT(S)ON VE E BRASS VALVE STEMS) <br /> FLEET INSPECTION MOUNT/D r LOO ALUTANUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILO(S; <br /> FLAT REPAIR(S) LOOSE oiSMOUNT(S) ALLIGATOR CAPS) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECOFJDITIONED VVHEEL(S) O RIrVG(S) <br /> OTY,. SIZE 1+'+'!',i+>'' MFG /} OESCRIP'TION FINISH Mil-ES <br /> ���O. ,f- !� ' ► 4 G(Q t?�-. L i_ . �.. STA?T MILES O <br /> TOTAL MILES: <br /> START TIME' lc�-Cr <br /> CNZITE TIME. ._ AM PMI <br /> OUT TIME RM P4° <br /> PUSH TIME- <br /> AM :d <br /> LOAD AMOU HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> -- ❑ AGRICULTURE ❑ COMMON CARRIERIBACK HAUL_ <br /> 'PICK U IMPORT FROM e �I( ' I COAD TYPE <br /> '� DELIVERY Y- + WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> t 2r EXPORT TO 6771 r ' ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> lrcerttty,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 <br /> e41c D°io am Jy.�re that f313111C2tiOn of this Information may result In civil pitnalties up to$25,000 per day,per vloiatlon or administrative penalties up to <br /> ao ES.000 per violat on per day as described in Public Resources Code eC't 42962 <br /> a <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No, Rn1 n ..�. _ ^ �. �...,. �.. .__,.. <br /> ZO 'd 60:ST 90GZ b'. qdd ^ TSOS-r'.bZ-601,,7:xed o i ait1 fi'[fl UDSit(fl <br />