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H90 'ON Ay- : [ SIH Zl 'AON aUll paAI D <br /> WILSON AYTIRE CO., INC. FLEET.SERVICE RECORD . <br /> U.S. TIRE SALES J50) --1 6 TPID 1000837. 15 4t * <br /> on Way Tire Wilson Way Tire Recap 902 Connell Tire 421 US Tire Sales 423 US Tire Sales 424 US Tire Sales <br /> Wifson ylay 1535 Market St. 2211 N.Wilson Shay 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd.- <br /> Ion, <br /> lvd.ton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 165-0281 209.465-3262 209-466-2561 209-571-5611 ' 510-887-1282 9f6.495-2245 <br /> OMER ` P.O.; DATE <br /> PHONE VEHICLE# <br /> S <br /> LICENSE# <br /> o�-1L.S <br /> !ON OF SERVICE STATE ZIP CODE <br /> G� <br /> JSTOMERTPID —m DECAL# <br /> ,rtrfy that under penalty of perjury under the laws orthe State of-California that the information provided above is true and correct.In addition,I am aware that fats fication of <br /> information may result In suspension;revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Publrc Resources Code section 42960 and may <br /> ,sult in civil penalties up to S75,000 per day,per violation of administrative penalties up to$5,00D per violation per day as described in Public Resources Colesectio 42962. <br /> ,dv=R NAME DRIVER <br /> IVER S1 TURE DATE <br /> CUSTOMERVEI-11,31-17-11INFORMATION <br /> MAY.E / TRUC ILER# LICENSE STATE ODOMETER)HUB <br /> vc(0,b <br /> _ '"`. %tiFSPECl1�L l>�. RUCT)O�.rc pits '3 �� 0`NYt � e +SOF cw c� r <br /> t Q7Y, �DESCt21PJlONOFWOKCOA4PLETEO,,faf�JYs y�,DESCf21pT101QFr1NORrCC07lPLETED . ,stQTY, .,� SCRIp,TiONOF.WOJ�ICCQMPtTEDR <br /> SERVICE CALL MOUNTI DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT)DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE?AOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIRS car <br /> LOOSE DISPAOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEELSWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> `'rrQT1SYe�'t_a.<'l_ S�Z 't t;r � _r 1r IMFOi1: f: Tw=� �:'-%ST^{:�10E$CRfPT10N.v •+x �t�_1 � i±2 FINISHMILES: <br /> 1Q f-2 START MILES: <br /> TOTAL MILES- <br /> f STARTTIME: <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: 1.2 <br /> LORD AMOUNT r s 3'r ;,' ` � :_tS'=::HHVLER EXEMPTION,IF_APPLICABLE;'= <br /> ❑ GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ———— —— ❑AGRICULTURE ❑CONIMON CARRIERIBACK HAUL <br /> �p :ti .< <br /> /PICK UP _LQAD.sTYRF-;�i , >a:° �;.i <br /> ❑ IMPORT FROM �1CLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑DELIVERY ,I <br /> VPORTTO ( ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty of perjury under the ws of thJ'.O <br /> forn' that the information provided above is true and correct.In addition,) <br /> oo`�DarO Pr am aware that falsification of this inrormatron may resunall' sup 25,000 per day, per violation or adnnistrative penalties up to <br /> Pp $5,0V erviolallonperday sdescribedInPublicResourco <br /> m '^ <br /> - Z <br /> CUSTOME RINT NAME DATE <br /> E'd e050I, £I- Z� AON <br />