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1 ,. <br /> WILSCf `NAY TIRE CO., INC. FLEET SERVICE REC <br /> �. TIRE SALES TPID 10008 7. 17 518 7 <br /> I Wilson Way Trre Wirson Way Tire Recap #02 Connell Tiro #21 US Tiro Sales 023 US Tire Sales #24 US The Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Mlson 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 510.887-1202 916-395-2245 <br /> CUSTOMER I P.O.-# DATE <br /> 4112 PHONE VEHICLE# <br /> LICENSE# <br /> f <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID DECAL# I <br /> 1>' }s -zr� I 1_�.t�-�_ice►�-, <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 Regisirmlon 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$5,0 r violation er day cribed I Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SIGNA UR DATE Q <br /> X < �� <br /> CUSTOMER • • <br /> MAKE TRUCKIrRAILER# LICENSE STATE ODOMETER#kiUe <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> s'`�jG�✓� �� � tom//��OIU <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. --- DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT 1 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 /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> QTY.• _. 'SIZE- - ._,.;_: .. 'Jvf�G --._, -: .,.,-:,�+.,:-DISGRIPTION ..;::�_ ,..,,:•,: FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> STARTTIME: AM PM <br /> ON SITE TIME: AM PIA <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE =r <br /> — • „/ ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> �Q ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PF�PICK UP <br /> t .r 1 <br /> C] IMPORT FROM WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> (3DELIVERY <br /> L3EXPORTTO ' Q VOLUME CUBIC YPIRDS L)WEIGHT IN TONS <br /> c DoroI certify that under penalty qperjury under the laws of the Stote of California that the information provided above is true and correct.In addition,I <br /> oc� r am aware that falsification of this Information may result In civil penalties up$25,000 par day,per violation or administrative penalties up to <br /> J $5,000 perlionperdayasdescribedinPublicResourcesCodesection42962. <br /> C ER PRINT N M CUSTOMER SIGNATURE DATE <br /> FSR No. 17 518 PLEASE CIRCLE STORE LOCATION AT TOP <br />