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WILSONY TIRE CO., INC. FLEET SERVICE RECORD 4> <br /> I� U.S. TIRE SALES TPID 1000837• 96529 } <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire 805 Wilson Way Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd 1915 National Ave. 6530 Franklin Blvd. j <br /> Stockton,Ca.95205 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.93823 { <br /> 209465.0281 209-465-3262 209.466-2581 209.835.4087 209.571.5611 510-887.1282 916.395-2245 <br /> CUSTOMER P.O. # DATE <br /> PHONE VEHICLE # <br /> M <br /> LICENSE # <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> - I <br /> CUSTOMER TPID _ i' i DECAL# <br /> I certify 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 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 civlf•penalt' s up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME/ t/ + DRIVER SIGN TWF3E - 1!._ DATE <br /> LIZ <br /> { A L G( A <br /> CUSTOMER VEHICLE <br /> _. <br /> •' • )� <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> IAL'INSTRkTIONS' ON <br /> QTY. DE$CRIP710N OF WORK COMPL ORK COMPLETED` OTY.' DESCRIPTION OF,,WORK CbMPL <br /> ETED QTY; DE,SCRIPTI.ON- IN <br /> SERVICE CALL 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 STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S) BALANCED METAL VALVE CAP(S) A <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> End <br /> PRODUCT INSTALLIt <br /> OTY.'`. CIZE".> MFG 015SCRIPTION ` FINISH MILES: <br /> START MILES: <br /> r TOTAL MILES: <br /> START TIME: AM PM <br /> is OMSIT!✓`TiME' — ,; - AM PM <br /> Iwo <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT " HAULLR LXEMPTION IF APPLICABLE <br /> / ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> 71 AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOADTYf?E <br /> ❑ IMPORT FROM .�--W OLE TIRE COUNT ElWEIGHT IN POUNDS <br /> ", El DELIVERY��,� El EXP O ❑ VOLUME CUBIC YARDS E] WEIGHT IN TONS <br /> I certify 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 <br /> 6'. $5,000 Doto, am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> $5,000 per violation per day as described in Public Resources Code section 42962. '• <br /> W <br /> Gr <br /> CUSTOMER PRINT NAME CUSTOMERY SIGNATURE DATE <br /> FSR No. �� w <br /> , f <br />