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R ! i Ike$ WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837. 81201 <br /> #01 Wilson Way Tire 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 /> 4 Stockton,Ca.95205 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209-465-0281 209-065-3262 209-466.2581 209.835.4087 209.571.5611 510.887.1282 916.395-2245 <br /> r CUSTOMER <br /> P.O. # DATE <br /> PHONE VEHICLE # <br /> LICENSE # <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID — 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 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 NAME DRIVER SIGNATURE DATE <br /> X <br /> •MER'VEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br />£i SPECIAL INSTRUCTIONS ON OFF <br /> rn, <br /> ee <br /> OTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> s 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) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br />£ PRODUCT INSTALLED <br /> QTY. SIZE I MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> k TOTAL MILES: <br /> arc. <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> J, <br /> iy <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> e ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> -- ®-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑ PICKUP LOAD TYPE <br /> ❑ IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ❑ DELIVERY <br /> ❑ EXPORT TO ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> I certify that under penalty of perjury under the laws of the Slate of California that the information provided above is true and correct.In addition,I <br /> roc Dato 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 /> N <br /> W d m <br /> r`IISTr)UF:Ft PRINT IAMF r111CTr1hJFR glr_p1I%T11RF nfTc <br />