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07/23/2009 04: 06 2094677" 95 WWT TRUCK PAGE 04/05 <br /> WILSOA# fr✓AI Y TARE C0.1 INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837 13 2 3 9 6 <br /> uhf Wil ort VIrAY'Tbvr Wilson Way TTm ReCwP #02 Connell 7WV 905 Wilson Why TV- /?i US Tire Sivinu J123 us Tiro Sn1n>= #24 U3 Tim Safes <br /> V.WH..on W41Y 153"1 Market 3t. 2211 N.Wilson Why f f33 W_0eventn St. 2G00 yfix aft Dfwt 1015 NnRfo.wl AVO. 663b Fknnklln Bhrot. <br /> ektod,Ca.0$705 Stockton,Ca-95=9 <br /> stockfon,en.90285 Tracy,Ce.95376 Modesto,CA..n 54 HaVw+rrd,Co.94545 SAamnnento,CA.45823 <br /> 20946'.3-O:tK1 T09„i6.~i+4'K2 209�165�2581 209.035-4097 209•ST1v01f 810.a8T.fRA2 916-"—P2245 <br /> CUSTOMER GATE r O <br /> �(���';-- vt�.! - - --- ' pl•IONE VEHICLE # <br /> I.IGENS # <br /> ODE <br /> LOOT O OF RVICE <br /> STATE ?5 C <br /> `� GO, � <br /> CUSTOMER TPID r Q DECAL# <br /> I certify that undnr ponnity of phriury undor the I-Iws of the$State of California that the Inform tion provided above In true and correct.In addition,t am Aware that fnisificstion of <br /> this Informntlon may result In suspension,revocation,or denial M renewal of the Waetn Tire Hatllar Registration pursuant to Public Resources 00410 section 42960 and may <br /> ranult In civil penaltlen up to ,000 per day,per violation or adminlAtt Alve penaltin!.up to$5,000 per vl noon per dey ar described In Public Re-'•oureea Cado Sectloa 42962. <br /> DRIVER NAME_ DRIVER SIGNATURE � �( DATE <br /> X. <br /> 7.r <br /> MAKE TRUCK/TRAILER 4 LICENSE STATE ODOMETER/HUB <br /> r� scar�"rioN dF.ttio ►rcaitfPc r�A arv. ;;DEdCAIF.riON oFWo KIP60PLATEtJ ; are. D89Cr:#i>l)V <br /> I^ SERVICE CALL rya MOUNT/OISMOUNT(S)ON VEHICLE / 't5 • BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S) I.00SE — ALUMINUM STEM(S) <br /> Alp SERVICE LOOSE MOUNT(S) VALVE STEM REBUILDS) <br /> LOOSE DISMOUNTS) ALLIGATOR CAP(S) <br /> FLAT REPAIR(S) _ _ <br /> REPAIR MATERIAL(S) _ — TIRE(S)Laat.ANCED — METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEI;L(S) O RING(S) <br /> SIS' MFG.. ' „ i_ • . . . RRIPTION F INISH MILE <br /> I 1 S; <br /> START MILES: <br /> �•. `\ /\ fes' TOTAL MILES: <br /> _ —— START TIME: a POPM <br /> ON SITE TIME: AM PM <br /> ^ OUT TIME: AM I'M <br /> — - w -- - — — FINISHTIME:r( �. � PM <br /> LOAD AMOUNT HAULER 8XEMPT16N j.F ApPLIC'ABLE <br /> ,.— — <br /> ❑ GOVERNMENT ❑ I.,CA EXEMPT ❑ OTHER <br /> -- °-- ❑ AGRICULTURE ❑ COMMON CARnIERBACK HAUL <br /> �j LOAD'TYPE:: _ <br /> '\ PIC 0U IMPORT FROM f / �' __ r�,o4 <br /> DELIVERY _ VVErIOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> I1 f �-1 <br /> v <br /> 0 EXPO19T TO 1'(Sdq L� ❑ VOLUME CUBIC YARDS f__1 WEIGHT IN TONS <br /> I certify that under penatfy of perjury tinder the laws of the.Stste of C illfornla that the Information proiridod above Is true and correct.In addition,I <br /> oa�4 15ofq pr am aware that falalficAtian of this inform?tion may rssli)t In elvll pan,"atlas up to$25,000 per day,por violation or AdminIsirntive penalties up to . <br /> �' Qa $5,000 por violation per day as decribed In Public Resources Code.Sectlon 42962, <br /> ER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. i �°� �C.>a � �„r �� a ctrrnoi:! I fV1ATlnnl AT Tnp <br />