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oiiEi) WILSON 6Y TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837 111028 <br /> #01 Wilson Way 11re Wilson Way Tire Recap #02 Connell Tire #05 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. <br /> Stockton,Ca.95205 Stockton,Co.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> Y09-465-0261 209.465.3262 209-4662581 209.8354067 209371.5611 510.887.1282 916-395.2245 " <br /> CUSTOMER , r� P.O. # DATE - y <br /> C_/ <br /> PHONE VEHICLE # <br /> LICENSE # <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> ;- -- Fe ._.. <br /> I <br /> CUSTOMER TPID ! I j —' DECAL# ,— <br /> _i_ _•_- <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 civil penalties 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 NAMEz DRIVER SIGNATURE DATE <br /> cusToMER VEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS " ON OEE <br /> �.1 LL <br /> U <br /> Q7 Y RIPTION�OF R!C'CbAlf�Ll TED ' QTY �' Vljlr' COMPLETED QT1'. DESC,RIPT(ON 6F.WORK CQMf <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSP CTION MOUNT/DISMOUNT(S)LOOSE _ ALUMINUM STEM(S) <br /> AIR SERVICE <br /> LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> t FLAT REPAIRS) LOOSE DISMOUNT(S))/ er)lJ /� ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) <br /> RECONDITIONED WHEEL(S) O RING(S) <br /> OTY) A4FG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> ~ TOTAL MILES: <br /> START TIME: AM PM <br /> N SITE TIME: AM PM <br /> r t i <br /> P";11 <br /> .... / r OUT TIME: AM PM <br /> d t` . <br /> i FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER X�MPTION IF APPLIC LE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> ---- •-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> LPICK UP - LOAD'TYPE <br /> O IMPO OM ����), ( ' ? ' WHOLE TIRE COUNT El WEIGHT IN POUNDS <br /> DE 1� 10 VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> EXPORT TO <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 /> �G DalO�r 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 /> moo ... $5,000 per violation per day as described in Public Fjeaourcea C gs/e�ot+oc�", 3`4�'2. <br /> • CUSTOMER PRINT NAME CUST ER SI NATURE DATE <br /> FSR No. 111028 <br />