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1-209-242-3051 14:33:32 10-29-2013214✓ <br /> r r WILSON V& TIRE CO., INC. LEET SERVICE RECORD ii 1'ak <br /> U.S. TIRE SALES TPID 1000837' 15 7 3 5 8 <br /> 01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 21 N.Wlison Way 1535 Market St 2211 N.Wilson Way 2000 Yosemite Blvd. 1816 National Ave. 6630 Franklin Blvd. <br /> (ocklon,CA 95205 Stockton,CA 86205 Stockton,CA 95205 Modesto,CA 95354 HayWard,CA 84545 Sacramenfv,CA 95823 <br /> 09-465-0281 208.469.3202 209-486-2661 200-571-5611 510.887.1282 810.385.2245 <br /> USTOWER P.O.# DATE <br /> PHONE VEHICLE <br /> LICEN # <br /> rn <br /> OCATION OF S RVICE STA ZIP CODE <br /> CUSTOMER TPID C qo L` ] DECAL# I-�_ <br /> tfy <br /> 1 cer that under penalty of perjury undar the IaWS of the State-ooflCelifomla that tho Information provided above Is true and correct In addition,I am aware that faleiticatlon of <br /> this Information may result In euaponalon,revocation,or donlal of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42060 and may <br /> result In civil penalties up to SZ5,000 per day,per violation of adminlstrattve panalties up to 55,oat1 par violudon per day as described In Public Resources Code section 42962. <br /> )RIVER E DRIVER SIGNAPiRE DATE <br /> X <br /> ORIOXI <br /> 1AAKE TRUCK/TRAILER It LICENSE STATE ODOMETERMUB <br /> dt tf ffift i 17 - <br /> ti11 e tT.' Riffl2ltit r r l { <br /> SERVICE CALL MOUNT I DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE . -i LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIRS) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> FINISH MILES: <br /> 1 R. rtsi. f r e � i 43 � i <br /> START MILES: <br /> TOTAL MILES: <br /> ST "TT1ME: AMP t <br /> ON SITE TIME: AM Ism <br /> OUT TIME: AM PM <br /> FINI511 TIME; '41`'f — <br /> !ffSe!?"ll <br /> tf.f�i! <br /> Fl� fit if w !'f: lC It 1s•.7;_ter ' ,� 1'rf )ti f t d CJ R �FJafr•l rr r. r <br /> LOAD AMOUNT . <br /> ❑GOVERNMENT [ILEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL t� f� # fel„?ff tr+1 �� :IFti•e1 = t? <br /> I l <br /> PICKUP <br /> LI IMPORT FROM WHOLE TIRE COUNT C]WEIGHT IN POUNDS <br /> DELIVERY VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> EXPORTTO <br /> I certify that under penalty or perjury under the laws o o State of Calition,I <br /> 'om a thakth fZ5,000oper day,per atlon IYlodletlonvor adrntntatrutiva ponaltloue 13 true and Gorraci.In i up to <br /> �c0arol� am avrare that falelfication of this Information rnny result In civil p p <br /> O,000per violation par day asdescribed inPublic ResourteaCode o 082 <br /> � � t�/ �r•�r-�-2 <br /> CU MER PRINT NAME <br /> GU MER SIGNATURE DATE <br /> r.c+n lu.. 1 F%Q PLEASE CIRCLE STORE LOCATION AT TLP <br /> Received Time Oct, 29. 2013 2 : 29PM No. 0862 <br />