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WILSON V'f� TIRE CO., INC. FLEET SERVICE RECORD U. IRE SALES TPID 1000837• 9 0 3 3 #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #05 Wilson Way Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. !— Adon,Co.95205 Stockton,Ca.95205 Stockton,Co.95205 Tracy,Co.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 35-0281 209465.3262 209-4662581 209-8354087 209-5715611 510-887.1282 916-395.2245 CUSTOMER P.O. # DATE PHONE VEHICLE # LICENSE# LOCATION OF SERVICE STATE ZIP CODE CUSTOMER TPID - DECAL# - 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 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 result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. DRIVER NAME DRIVER SIGNATURE DATE X CUSTOMER •- • MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB SPECIAL INSTRUCTIONS ON OFF i Y. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) PRODUCT INSTALLE>r OTY. 1 SIZE MFG DESCRIPTION FINISH MILES: START MILES: TOTAL MILES: START TIME: AM PM ON SITE TIME: AM PM OUT TIME: AM PM FINISH TIME: AM PM LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER -- •-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL ❑ PICK UP LOAD TYPE ❑ IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS ❑ DELIVERY ❑ EXPORT TO ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS DarQ 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 �or� Tro am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to yN S5,000 per violation per day as described in Public Resources Code section 42962. CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE FSR No. ;0 1 i ;