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✓VILSC AY TIRE CO., INC. FLEET SERVICE RECORD <br /> TIRE SALES TPID 1000837 175938 <br /> ­6 In Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 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 <br /> 209-465-0281 209-465-3262 - 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CU OMEP.O.# DATE <br /> PHONE VEHICLE# <br /> 0 101 <br /> LICENSE# <br /> LOPKION QF SERVICE STATE ZIP CODE <br /> Ca qc5ace2- <br /> CUSTOMER 4D l I I—! DECAL# <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 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 DRIVER SIGN E DATE <br /> X <br /> CUSTOMER •-MATION <br /> MAKE U TRUCK/TRAILER# LICENSE STATE ODOMETERIHUB <br /> oUza- )a- a <br /> SPECIAL INSTRUCTIO S , ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL I MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNIT/aTS--MOUNT(S)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) TIRE(S)BALANCED I METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> I nh START MILES: <br /> 1fJ l TOTAL MILES: <br /> START TIME: AM <br /> ON SITE TIME: Ann PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM M <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> -- I <br /> []GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> {-• ❑AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> LJ IMPORT FROM WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ELIVERY <br /> ❑ EXPORTTO VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> 1 certify that under penalty of perjury under t e aws of the State of California that the information provided above is true and correct.In addition,I <br /> c DoroTrG am aware that falsification of this Informal. may result in civil penalties up$25,000 per day,per violation or administrative penalties up to <br /> $5,000 per violation per day as described in Public Resources Code section 42962. <br /> w m <br /> • CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> coo Iki— '7KzQI 1 Q <br />