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WILSON WAY TIRE CO., v�cE RECORD <br /> U.S. riRF sacEs 1000837• 184617 <br /> #01 Wilson Way Tire Wilson Way Tiro Recap #02 Connell Tire #211 US Tire Sales #23 US The Stiles 924 US Tire Sales <br /> 221 N.Wilson Way 1535 Market SE 221f N.Wilson Way 2600 Yosemlle Blvd, f9f5 Na/IonalAve. 6530Franklln Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209.465•0281, 2094603262 209466,2581 209.57!•5517 Sf0,887-1282 916-395-2245 <br /> CUSTOMER h P.O.# - DATE <br /> PHONE VEHICLE[# <br /> 44 <br /> LICENSI# <br /> LOCATION OF SERVICE STATE i�.jvZIP CODE <br /> C4 4 . <br /> p r <br /> CUSTOMER TPID 11;81/ P� 1_ DECAL# <br /> I certify(hat under penalty of perjury under the laws of the Slate of California that the Information provided above Is true and correct.In addition,I am awale that falsification of <br /> this Information may result In suspension,revocation,or dental of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result In civil penalties up to 825,000 per day,per violation of administrative penalties up to 85,000 per violation per day as described In Public Resources Code section 42952. <br /> DRIVER NAME DRIVER SIGNATUR DATE <br /> X <br /> CUSTOMER •' • <br /> MAKE TRUCIUTRAILER# I �,�-i^ v 1007 JNSE 3.0 4v SYA7E� 1ID3 E;1. <br /> SPECIAL INSTRUCTIONS , ON OFF <br /> DESG OFWgRKCOMPLETED QTY DESCRIPTION OF WORK COMPLETED QTY. 6ESCRIPTIONOFWORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT 1 DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILDS) <br /> 'FLAT REPAIR($) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> QTYI Sri MFO DMM/P77ON FINISH MILES: <br /> START MILES:.233.0c=1 <br /> a2l. ' oA TOTAL MILES: <br /> v STARTTIME: g:�S C4 PM <br /> ON SITE TIME: & PM <br /> OUT TIME:1 21 AM <br /> FINISH TIME: 2.'.2 '� Am PM <br /> LOAD AMOUNT _ HAULER EXEMPTION IFAPPLICA1'34& <br /> Q GOVERNMENT QLEA EXEMPT Q OTHER <br /> • Q AGRICULTURE Q COMMON CARRIER/BACK HAUL <br /> -Q PiCK UP LOAD <br /> Q IMPORTFROM ;ctNHOLE TIRE COUN� Q WEIGHT IN POUNDS <br /> aDELIVERY <br /> C3 EXPORT TO Q VOLUME CUBIC YARDS Q WEIGHT IN TONS <br /> Data i dertify that under penalty of perjury under the taws of the Stale o Callfornls the he tufo tion prIovlded above Is true and correct.In addition,I <br /> ed T, am aware that falsification of this Information may result In ci penal tle u 25,000 er day,per violation or administrative penalties up to <br /> S$OOOpervlotatlonperda asdescribe`dInPublicResources section <br /> � Q `I`Gt.�tA1KQ - <br /> CU6TOMERPRINTf4AME T ER SIGNATURE DATE <br /> FSR No. 184617 PLEASE CIRCLE STORE LOCATION AT TOP <br />