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- r <br /> WILSON WAY TIRE CO., INC, C�i � ' FLEET SERVICE RECORD <br /> U.S. TIRE SALES Zr TPID 1000837• 117 413 <br /> d01 Wilson Way Tire WReorr Way Tina RSCap p02 Cwenell Tiro X05 Wilson Wry Tiro def US The Salru p23 US Tiro Saks p9i Us Tire 56100 <br /> 221 AL Wfton Way, 1530 AfArket$t. =I f N.1Nlkon W" f 733 W.Elaventh SL zM Tosamlte Blvd f978 Alstlor12l11— 81+7p Frankjfn aftgL <br /> St—kr-'Op.$5z(k5 stooktam Ca 98240 5toCkton,Ca.95205 Tracy'Z`y,93976 Modesto,C&!Wa$4 Hayward,t a.94585 Sacramento,CA.95= <br /> 20&48A-0291 y09465s262 2pg4ti6•.Zst;f 209.899-1097 290.5714611 Sf0.9191-1202 916.395.22" <br /> CUSTOMER P.O.# DATE <br /> 57 <br /> PHONE VEHICLE A <br /> LICENSE# <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> ti r �76- � <br /> CUSTOMER TPID (7 ...C..� DECAL l! ...� CA <br /> I oertify 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 taleitication of <br /> this Information may result in suspenslon,revocation,or denial of renewal of the Waste Ylre Hauler Registration pursuant to Public Resources Coda section 42960 and may <br /> result in civil penalties up to 32b,000 per day,par violation or administrative penalties up to$5,090 per violation per day aa geaerlbad in Public Resources Codc w0lon 42962. <br /> DRIVER NAME DRIVER SIDATE <br /> CUSTOMER VEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY DESCRIPTION OF WORK COMPLETED OTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPI-!ON OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE$I'i;M($) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM($) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILDS) <br /> FLAT RAPAII4($) LOOSE DISMOUNT($) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL($) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) C7 IxlniG(S) <br /> 07?, SIZE. MPO DESCRIPTION FINISH MILES: <br /> Jr START MILES; <br /> TOTAL MILES: <br /> STA11'r TIME; AM PM <br /> ON SITE TIME; AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME; AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> — 2 _ 0 GOVERNMENT [7 LEA EXEMPT 0 OTHER <br /> Q AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP01 LOA TYPE <br /> ❑ IMPORT M .fid o►u HOLE TIRE COUNT 0 WEIGHT IN POUNDS <br /> ❑ <br /> ❑ EXPORT TO ❑ VOLUME CUBIC YAAOS ❑ WEIGHT IN TONS <br /> I certify that under penalty of jury under the laws of the State of Cautornia that the information provided above i3 true and correct.In addition,I <br /> �c palq am aware that falslllcatlon o this information may result in civil to$25,900 per day,per violation or adminlWattive penalties up to <br /> $S,OUO per violation par day as described in Public Resoure d ecti <br /> � m <br /> CUSTOMER PRINT NAME CUSTOMER NATUR DATE <br /> FSR No. 117 413 <br /> TO 39Vd VWOO 3dI1 AVM NOSIIM EZOV59V6OZ OZ:5T 8003/90/90 <br />