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WILS!% WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> 3. TIRE SALES TPID 10008 17 212 3 <br /> 2ktom <br /> lson Way Tire W,rson Way 71re Recap 602 Cannell Tire #21 US Tire Sales #23 US Fire Sales #24 US Tire Sales <br /> Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 NationarAvc, 6530 Franklin Blvd. <br /> CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 109-465-0181 109-465-3262 209-466-2581 204-571-5611 510.887-1282 916-395-2245 <br /> �USTOMER P.O.# DATE <br /> ro �✓t� / 3-9s / L- L t- ►y <br /> PHONE VEHICLE# <br /> l z2r <br /> 0�) LICENSE# <br /> 6A/2 Z--5.�S <br /> _OCATION OF SERVICE STATE ZIP CODE <br /> 1 <br /> CUSTOMER TPID I '' /1�J—�� DECAL# II� �—��#- TT/! <br /> I certify that under penalty of perjury under the laws of the State of Callfornla that the Information provided above is true and correct.In addition,I am aware that falsifiention of <br /> Ws Information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code secllon 42960 and may <br /> result In civil penaltles up to$25,000 per day,per violation of administrative penalties up tc 5,000 per violation per day as described in Public Resources Code section 42962, <br /> DRIVER NAME DRIVER ATURE DATE <br /> f X 1—I 1 <br /> MAKE TRUCKIfRAILER# LICENSE STATE ODOMETER HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> //2-z7- <br /> s -- ------ ---- — - --- --- -- -- <br /> �� -------- <br /> A <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 1 DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISNIOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEELSWITCH(S) RECONDITIONED WHEELS) O RING(S) <br /> PROIDUCTINSTALLED <br /> QTY SIZE MFG DESCRIPTION FINISH MILES: / <br /> — START MILES:�CO <br /> f TOTAL MILES: <br /> µ START TIME: AM PM <br /> ON SITE TIME: AM I'M <br /> OUT TIME: AM PM <br /> FINISH TIME: '3o AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> Q GOVERNMENT 0 LEA EXEMPT ❑OTHER <br /> --——— (� Q AGRICULTURE Q COMMON CARRIER/BACK HAUL <br /> 4FICK UP _ LOAD-TYPE <br /> L3 IMPORT FROM rr �W HOLE TIRE COUNTQ WEIGHT IN POUNDS <br /> LIVERY <br /> ❑ EXPORT TO G e ❑VOLUME CUBIC YA(2DS Q WEIGHT IN TONS <br /> 22n1 corttfy that under penalty of perjury under the laws of the State of California that the Informatio provided above is true and correct.In addition,I <br /> 00'6 DotoA� am aware that falsificatlon of this information may result in civil penalties up 525,000 per y,per violation or administrative penalties up to <br /> b l $5,OOD per violation per dayasdescribecl in Public Reso6rce5 Code saction42962 <br /> 90c1119 J�,� <br /> CER PRINT NAME C S OMER SIGNATURE DATE <br /> FSR No. 17 212U MPLEASE CIRCLE ST RE LOCATION AT TOP <br />