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WIL c ' WAY TIRE CO., INC. FLEET Ei�VIL RECORD <br /> J.S. TIRE SALES TPID 10008371812 5 3 <br /> oc <br /> \pyAlson Way Tina 1•'Y71son Way Tire Recap #02 Connell Tire #21 US Tire Sales 923 US Tire Sales #24 US Tire Sales <br /> N.Wilson Way 1535 M1larkof St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> cktan,CA 95205 SfeocWR,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> A-4650281 9-465- 262 209.466.2581 209.571-5611 510-687-1282 916-391-1-2245 <br /> /USTOMEnew v P.O.# DATE <br /> t;a,� —t <br /> PHONE VEHICLE# <br /> /) LiCENSE# <br /> tV/ I I <br /> \5-4,3-3C� <br /> LOCATIDN OF SERVICE STATE ZIP CODE <br /> s <br /> 10019 CAS <br /> CUSTOMER TPID DECAL j _ 1315 + <br /> I certify that under penalty of perjury under t e 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 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 NAME DRIVER SIGNATURE DATE <br /> X <br /> CUSTOMER •- • <br /> MAKE TRUCKTfRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> :yo To �ra✓lncvl Tfl Pte k P -- - --- - -- -- -- — - -- <br /> (p.fao <br /> i�r tl'4•" <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> r SERVICE CALL (X./ 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 STENT REBUILD(S) <br /> FLAT REPAiR(S) LOOSE DISMOUNTS) 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 O <br /> QTY. SiZE MFG DESCRIPTION FINISH MILES:-23,Aj -7 <br /> ��' �� ` ,O ) _lN_/y START MILE / 7 - <br /> / C� TOTAL MILES: 61 d <br /> STARTTIME: CAO M <br /> ON SITE TIME: :40`1— <br /> A<D <br /> OUT 71ME: /• AM Pea <br /> FINISH TIME: ADA PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> — _ Q GOVERNMENT Q LEA EXEMPTOTHER <br /> —�— Q AGRICULTURE Q COMMON CARRIERIBACK HAUL <br /> PICK UPLOAD LOAD TYPE <br /> C3 IMPORT FROM =1L WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑ EXPORT TO a , ❑VOLUME CUBIC YARDS L]WEIGHT IN TONS <br /> DorQ I certify that under penalty Qf perjury under the laws of the SIX of California that the informs provided above is true and correct.in addition,I <br /> �o� 1t am aware that falsification of this information may result In dull penalties up$25, 0 day, er violation or administrative penalties up to <br /> i l;� S 5,000 parViOl2lion parday ps described In Public Resources Co do section 4 ../ <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 181253 PLEASE CIRCLE STORE LOCATION A TOP <br />