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Vit,,I WILSOft Y TIRE CO., INC. % FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 000837- 80583 <br /> #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 <br /> 221 N.Wilson Way 1535 Market St. 2211'N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> 11 Stockton,Ca.95205 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209-465-0281 209-465-3262 209-466-2581 2094835-0087 209-571-5611 510-887-1282 916-395.2245 <br /> CUSTOVE 1 �� P.O. # D — <br /> Ia� ire ( <br /> PHONE VEHICLE,# <br /> r G <br /> LICE. SEt r1 <br /> LOC` T 'OF SERVICE TE V ZIP CODE <br /> I - _ <br /> CUSTOMER TPID — DECAL# r �� <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 /> r 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 dat,per violation or administrative penalties up to$5,000,per violationday as described in Public Resources Code section 42962. <br /> DRIVER NAME - DRIVER S T c �j� DATE <br /> x 6 - �?- c; <br /> INFORMATIONCUSTOMER VEHICLE <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> r- <br /> SPECIAL INSTRUCTIONS ON OFF <br /> F <br /> /QTY. DESCRIPTION OF WORK COMPLETED QTY, ?SSCOMPLETED QTY DES F WORK COMPLETED <br /> J <br /> SERVICE CALF MOUNT/DISMrn InLT ICLEBRASS VAL VE_STEM <br /> E FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> F <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> R <br /> r FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> I <br /> REPAIR MATERIAL(S) TIRES)BALANCED METAL VALVE CAP(S) <br /> F <br /> E WHEEL SWITCH(S) RECONDITIONED WHEEL(S) LO RINGS) <br /> I, <br /> PRODUCT INSTALLED <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> i 7 <br /> T�- O START MILES: ' <br /> TOTAL MILES: <br /> [- START TIME: ` AM PM <br /> i <br /> e <br /> ON SITE TIME: fir) (JA PM <br /> P OUT TIME: / S AM P��M/ <br /> r <br /> FINISH TIME: o-, AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK IJP i 1` LOAD TYPE <br /> {J IMPORT FROM %` WHOLE TIRE COUNT El WEIGHT IN POUNDS <br /> E [}'DELIVERY / ,r Q' EXPORT TO El CUBIC YARDS F1 WEIGHT IN TONS <br /> G!�';� tee`' / <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 <br /> r,�Dolo-r 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 <br /> �� oY $5,000 per violation per day as described in Public Resources Code section 42962. <br /> w m <br /> , v <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR NO. :, , <br />