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1-209-242-3051 14:34:28 10-29-2013 4;41 <br /> t . WILS0AAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837- 153749 <br /> #01 W(ison Way T7ry Wilson Way T7re Recap #02 Connell Tire #21 U5 Tins Setas <br /> 221 N.Wilson Way 1535 Market St 2211 NW)lson We #23 US Tire Sales #24 US T7re Sales <br /> 'Stockton,CA 85205 Stockton N.CA 95205 y 2600 Yosemite Blvd. 1015 National Ave, 11530 Franklin Btvd. <br /> 209 485 0281 209-465-3262 <br /> Stockton,CA 95205 Modesto,CA 9535a Hayward,CA 94545 <br /> 209-466.2581 209571-5811 570-887-1282 Sacramento,CA 4582:CUSTOMER P.O.# <br /> DATE 916195-2245 <br /> PHONE VEHICLE <br /> FQ� LICENSE <br /> LOCATION OFS VICE <br /> STATE ZIP CODE eft I <br /> CUSTOMER TPID L I�( —L/ DECAL# m—I^ ji <br /> I certify that under penalty of pedury under the laws of the State of ICallfornla that the Information provided above Is true and correct.11 In11 addition,Ilam beware that falsiflgUen of <br /> this Information may result In suspension,revocallon,ar denial of renewal of the Waste Tire Hauler Reglrtratlon pursuant to Public Resources Coda section 42900 and may <br /> result In civil penalties up to$25,000 per day,par violation of administrative penalties up to 55,000 per violation par day as described In Public Raeources Code sactlon 42002. <br /> DRIVER,IA41ME DRIVER SIGN RE <br /> v DATE <br /> A <br /> MAKE TRUCWTRAILER# LICENSE STATE ODOMETERMUH <br /> MUMMA MEW <br /> SERVICE CALL MOUNT/DISMOUNT(5)0 N VEHICLE BRASS VALVE STEMS) <br /> FLEET INSPECTION MOUNT!DISMOUNT(5)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE DOSE 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 /> FINISH'MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> 777P STARTTIME: AM PM <br /> ON SITE TIME AM pM <br /> OUT TIME-_AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT <br /> _ — ❑GOVERNMENT ❑LEA EXEMPT Q OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP <br /> Q.IMPORT FROC�ao III 01111i 1:1111111111111,111111111ftu��� <br /> M <br /> XELIVERY WHOLE TIRE COUNT <br /> Q EXPORT O WEIGHT IN POUNDS <br /> VOLUME CUBIC YARDS ❑WEIGHT IN TONS. <br /> W Datq t certify that under penalty of perJury under the lawn of the& of CnllII lhet the Inlorrnat10r1 provided above Is true and correct.In addlUan,1 <br /> Jo° ri am aware that falelflcation of this Information may result I civil pe at a up$25,000 per day,per violation or administrative penalties up to <br /> �+ �? SS,000parvlolatfonpardayeed ribedlnPublEcRasourcesCodaa c o 42802 <br /> � o <br /> l tpT,, <br /> CU91TOMER PRINT NAME CUSTOMER SIGNATURE <br /> DATE <br /> FSR No. 153749 PI f=A.qF r.lAr i IZ7 QTno= I r,r•A-rl—.I <br /> Recelved Time Oct, 29, 2013 2 . 29PM No. 0802 <br />