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WILSC?- OY TIRE CO., INC. FLEET SERVICE RECORD <br /> TIRE SALES 4 TPID 1000837 175932 <br /> i Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US The Sales #24 US Tire Sales <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 <br /> 209.465-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916.395.2245 <br /> CUSTOMER P.O.# DATE <br /> � <br /> PHONE VEHICLE# 1 <br /> I <br /> LICENSE# <br /> LOCATI N OF SE CE STAT ZIP CODE <br /> CUSTOMER TPID DECAL# l.�.. I �l al► �. I . <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,1 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 N DRIVER SIGNATPRF DATE <br /> X <br /> 6.�— <br /> CUSTOMER VEHICLE INFURMATION <br /> MAKE TRUCK/TRAILER# U LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> l SERVICE CALL ok MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(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 METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> PRODUCT <br /> SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: l <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME:. (_�_A PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT LJ LEA EXEMPT LJ OTHER <br /> ----a\*- - ❑AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP NVOLUME <br /> D TYPE <br /> L] IMPORT FROM WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> DELIVERY <br /> LJEXPORT TO CUBIC YARDS ❑WEIGHT IN TONS <br /> c <br /> Data I certify that under penalty of perjury under the I s of the State of California that the Information provided above is true and correct.In addition,I <br /> sots T�� am aware that falsification of this information may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> A $5,000 per violatlon per day as described in Public Resources Code section 42962. <br /> w <br /> �io <br /> • CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 17 5 9, 3 2 F11 c n c r r+enn, r <br />