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WILSON A Y TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES <br /> TPID 1000837. 106360 <br /> i #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #05 Wilaon 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. <br /> Stockton,Co.95205 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Co.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209463-0281 209.4651262 209-466-2581 209-8354087 209.571.5611 510-867.1282 916395.2245 <br /> CUSTOMER - _ <br /> / G r. `J. P.O. # DATE / _ _� <br /> C .. / y s L9 f <br /> /� ) �• `_ j• /`'/�../'/J r� -� PHONE VEHICLE# � —LICENS <br /> f r <br /> LOCATION OF SERVICE STATE , ZIP CQDE <br /> CUSTOMER TPID DECAL # �( —'6 <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 tfauler Registration pursuant to Public Resources Code section 42960 and may <br /> result in civil penalties up to$25,000 per day,per violation or administrative penalties up t245,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER,$r0NATURE DAT <br /> CUSTOMER <br /> •- • <br /> MAKE TRUCKITRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTION ON OFF <br /> Q WORK GDMPC�TYD QTY. DESCRIPTIdM WORK COMPLETED QTY. +"' !aYlON OFWORk'COMPLETED: <br /> DESCRIPTION OF F <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 MATERIALS) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> -�imum= <br /> MEG CRIPTIQN FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START 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 /> I )EHGOVERNMENT ❑ LEA EXEMPT ❑ OTHER AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> ❑ IMPORT FR WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> DELIVERY � <br /> ❑ EXP TO ,2., /5 4; ,,� �it��?f% � ilf� ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> I <br /> `c Daro I certify that under penalty of perjury under rime laws of the State of California that the information provided above is true and correct.In addition,I <br /> Soo Tr 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 /> CUSTOMER PRIN E CUSTOMER SIGNATURE <br /> SSR No. 106360 DATE i <br />