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JUN-l�-2005(>y`EDi 0806 - H Tracy, C OF 11"x83 W8 P, 008/013 <br /> WILSON'WAY,TIRE' CO., INC.. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837-' 81175 <br /> 101 Wfban Way n d Wilson Way 74.'Raeap i •pz Garma The Ap Way T4. azf U8 TLe Sales 1129 Its Th.Sales #ad US Tile saw <br /> 221 AL lrrl—Way lana AL—k t At., 2211 iL Will—way 1193 W.Eler—U St. --anti Y.40"*9 BIM. 181 Itlallorral Ara G=Irmnksn plvd. <br /> sladtean,Ca.B72d9 5rt>rlrron,Ga.parva stamen%CA.omw Tracy,102.9s97e Mos t..ra 1115its4 May— Ca,945" sacrar entq ri.aa:_ <br /> zoaoas-0ae1 2trstaaa2az r 1 asal; 20941034m7 zor:dTl air Q elana7.1m 916,795224B <br /> CUSTOM - t��� UTTIE: Lji P�i� 41 f t BATE . <br /> �] <br /> PHONE VEHICLE H <br /> LICENSE k <br /> LOCATION OF SERVICE ; � /I, ,�r� � N ,�� � ; Z1P�t CODE <br /> CUSTOMER TPIDLIT_..�.T.l_. I 1� DECAL 8 <br /> J.�— <br /> I certtry that under penally of penury under[he laws of the State or Calllornla that lite Information provided above Is lrueAnd correct.Ip addition,I am aware that falsification of <br /> this Inlormetlon may reoull In suspension,revocation,or denial of renewal of the Waste Tire Itauter RoUlstratfon pureuani to public Resourcee Code section 42060 and may <br /> result In civil fwnalties up to S25,o00 per tray,per violation or administrative panablea up to 55,000 per vtatallori per day es described In Public Reeources entre section 42902. <br /> DRIVER NAMEL-D D IVER SIGNATURE DATE <br /> •&Jr <br /> ;Fj VEHICLE INFORMATION <br /> MAKE TR � �) p M NJ( STATE ODOMETEFI/HU6 <br /> 7,'/1'71 <br /> ,gyp .,, 1 „•n..Y n,r rqi,.a. .rw, m,ury <br /> VA.p.�• .� .•r. ,r•a <br /> • ",',',•;�•••a,;mu5 ECI 5 CIONS d"61 �..°,�Iilli�t f � ^1 .� F.•ONwrYnPf.p rl r• f» tfrOFF•�. •.,,•.,'+ . <br /> j <br /> —4 <br /> ....,.... — - .. •__ <br /> oTv. 13E3c{?IPTIi7N°OF LvoRK,GpMryLiTEd a?x' ",,:°'DESCI�Ir*flon t7(=:Wc7t�k CaAfF T1 D q7Y'. .;'+.OESCAII�oryOFWoHKCOMPLETEP':.e <br /> O RVICE CALL MOUNT/DiSMOUNT(S)ON VEHICLE, U BRASS VALVE STEM(S) <br /> FLEL7 INSPECTION MOUNT I DISMOUNT(S)LOOSIE ALUMINUM STEWS) <br /> `AIR SERVICE LOOSE MOUNT(S) p� VALVE STEM REBUILD(S) <br /> FLAT AEPAIR(S) LOOSC DISMOUNTS) } ALLIGATOR GAP(S) M <br /> IIEPAIPI MATERIAL(S) TIRE(S)BALANCED A METAL VALVE CAP(S) <br /> WFiCGL SWITCH(S) RECONDITIONED WHEELS) Q RINO(S) <br /> SIZ r. . FINISHMILEa: <br /> START MII.ES: <br /> TOTAL MILES: <br /> t <br /> START TIME Gr '� nu Yu <br /> ON SITE TIME: AM IM <br /> t OUTTIME AM I'M <br /> t <br /> FINISH TIME w vu <br /> LOAD AMOUNT " "A y MPTIbN rIF APF�CICABCE"' "' " <br /> CI GOVERNMENT �[I LEA EXEMPT ❑OTHER <br /> '-"�—� • — O AGRICULTURE El COMMON CAARIERI6ACK HgUL <br /> LOAD TYPE:" <br /> ❑ PICK UP <br /> ❑ DEUVE IMPORT FFOM El HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> IJ EXPORT TO p VOLl1ME CUBIC YARDS El WEIGHT IN TONS <br /> i <br /> tier I certify that untie(pmt0lly of perjury under the law$of Ili*Glals of California that the I Wrmatlan provided above is true and torted.In addlLlon•1 <br /> Q'T am aware that lalelllcatlon of this Intdmallon may result In civil penalties UP m$2 per day,per violation er adminkrrailve penalties up is <br /> a p� 59,000 per violation per day as doscrlbsd/In Public Neeources Code action 42 <br /> CUSTOMER PRINT NAME' CUSTOMER SIGNATURE DATE <br /> FSR NO. 81176 <br /> I t^ r l <br />