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11. 2008 3.41 PM WI[""°I WAY TIRE CO. 219 242-3051 No. 9851 4/4 <br /> WILSON I f TIRE, CO., INC. SET SERVICE RECORD <br /> Qw— D U.S.;TIRE SALES TPID 1000637. 113747 <br /> ...,'Kisott Way Tlne Wflaon Way 77re Recap t02 cap ll Tiro BOD WiL—Way Tire 031 US rfi-Sales 023 US Tiro Saba 024 US Tire Sale? <br /> 221 N.I ileon Way :1635 Market St. 2211 N-Wlls°n Way 1139 W.Eleventh St. 2600 Yosemi!e Blvd. 1918 Nationai Ave. 6530 Franldin Blvd. <br /> Stockton,Ca.963o5 Stockton,Co.85205 Sfockton,r—93204 Tracy,Ca.96376 Modesto,CA.95364 Hayward,Ca.94646 Sacramento,CA 96623 <br /> R0948B.o281 309-4&1.9463 20946&2581 209.891-4097 209-D71-6811 BIO-987-1292 918.396.2M <br /> CUSTOME P.O. # D E <br /> PHONE VE LE# <br /> LICENSE # <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> P LP <br /> CUSTOMER TPiD 1— DECAL# <br /> I certify that under penalty of perjury under tho laws of the State of California that the Information provided above i5 truo and corroct.in addition,I am aware that falsiflcatlon of <br /> this Information may result In suspension,rovocatlon,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> re,suh In civil penalties up to$25,000 per day,per viciatlon or administrative penalties up to$5,000 per violation per day as descrlbod In Public Resources Code section 42962. <br /> DRIVER NAME DRIV NATURE DATE <br /> X Y Q <br /> CUSTOMER VEHICLE INFORMIATION <br /> MAKETRUC RAILS LICErj SPATE ODOMETER/HUB <br /> r N <br /> pkSPECIAL'INSTRUCTIONS OFF <br /> "DESCRI OMPL'67ED ('; +'L]TSr <br /> +3?7 5 TION+OFWORK.� t' `DESCRIPTION OP ETEO y. OTY DESCRIPTION OF WORKCOMPLETF_0 <br /> �ERVIOE CAL OUNT/DISMOUN't(S)ON VEH BRASS VALVE STEM(S) <br /> FI-FET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(-5) <br /> FLAT REPAIR($) 1 LOOSE DISMOUNT(S) ALLIC,aATOR CAP(S) <br /> PAIR ERIAL( / TIRE=($)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> :OESCRIPTI :o-•„i' �1f,. FINISH MILES; <br /> START MMES: <br /> TOTAL MILES: <br /> START TIME: ati GM <br /> 1(7 <br /> ON SITE TIME: AM PM <br /> OIJT TIME: AM PM <br /> FINISH TIME; <br /> LOAD AMOUNT - HAULER':EXEMPT,IONrIF APPLICABLE <br /> —_ ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> I❑ AGRICULTURE L7 COMMON CARRIER/BACK HAUL <br /> PICK UP <br /> T FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> 7 DELIVERY <br /> ❑ <br /> L7 EXPORT TO VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty of penury under the laws of tho State of Callfornla that the Information provided above is true and correct.in addition,I <br /> oo�c D°for em aware that faielflcatlon of this information May result In civil ponillles up to$25;000 per day,per violatlon or administrative penaltio, up to <br /> p $5,000 per violation per dae tlostrigea In Public Resources Code section 42962. <br /> � 6 i (.10 <br /> r� <br /> CUSTOMER SAME CUSTOMERS J,/RE' baTl <br /> .. •-• I A .-.1 • .. <br />