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. t WILSr AY TIRE CO., INC. FLEET SERVICE RECORD <br /> 3. TIRE SALES _ TPID 1000837. 17 5 6 9 3 <br /> a01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #11 US Tire Sales #23 US Tire 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 /> CUST ER , P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCe OF SE CE f/ STATE ZIP CODE <br /> �V <br /> �! I <br /> CUSTOMER TPID i-T� ` I DECAL# � I <br /> I certify that under penalty of perjury under the laws of the State of California that the informati ided above is true and correct.In addi ion,llam aware that falsification of <br /> this information may result in suspension,revocation,or denial of renewal of the Waste Tire auler Re 'stration pursuant to Public Resources Code section 42960 and may <br /> result in civil penalties up to$25,000 per day,per violation of administrative penaltie up to 000 pe vi on per day as described in Public Res o rtes Code section 42962. <br /> DRIVER NAME ry I X IVE IGN T / <br /> CUSTOMER • C/d <br /> MAKE TRUC TRAILER# LICEN E STATE ODOMETER/HUB <br /> sa - <br /> 3791 �` a - <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> (� l ler �( > �22� • _ .. _._ ._._ .._. <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE ` BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> QTY. SIZE MFG DE IP ON FINISH MILES: <br /> If` 'T�C Q START MILES , <br /> J TOTAL MILES: <br /> STARTTIME: PM <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINI$H TIME:Yr U0 Aji <br /> LOAD AMOUNT _ HAULER EXEMPTION IF APPLICABLE <br /> ——`_ 1 • <br /> LJ GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP rUn, AJ' ZLOAD TYPE <br /> ❑ IMPORT FROM ` ❑WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY <br /> ❑ EXPORTTO ) ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty of perjury under the laws of the St to of California that the information provided above is true and correct.In addition, <br /> or�c DafoT'� am aware that falsification of,th-s Information may re 'I <br /> civil penalties up$25,000 per day, per violation or administrative penalties up lr <br /> $5,000perviolation per day as d ribed in Pu Reso es Code section 42962. <br /> d // <br /> w • � — <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />