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{{tr�a <br /> WILSON WAY TIRE CO., INC. EIV { ET SERVICE RECORD <br /> U.S. TIRE SALES 1000837• 18 4 6 0 8 <br /> 1101 Wilson Way The WI/son Way Tire Recap #02 Connell Tire 421 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.NMlson Way 1535 Marker St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 HatlonalAve. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94345 Sacramento,CA 9582, <br /> 109.4650281 109.465-3262 209.466.2581 209.571-5611 51-887-1282 916.395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> !3Y <br /> LICENSE# <br /> S <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> a r <br /> f--- , AC _. � .�t 1 <br /> T� # <br /> CUSTOMER TPID DECAL <br /> } �` r;} Q <br /> 1 certify that under penalty of perjury under the laws of the Slate of California that the information provided above Is true and corret.In addition,l 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 sectlon 42960 and may <br /> result In clv9 penalties up to$25,000 par day,per vlolation of administrative penalties up to$5,000 per violation per day as describ4d In Public Resources Code section 42982. <br /> DRIVER NAME DRIVER SIGNATUR DATE <br /> x 43' <br /> MAKE TRUCK/TRAILER it LICENSE ! STAT OOOMETERIHUB <br /> -7 4IW <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY. 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 STEMS) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIRS) 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 MFG DESCRlPT10N FINISH MILES: <br /> START MILES: <br /> Sr fflival TOTAL MILES: <br /> STARTTIME: 4 rJ �P>t <br /> ON SITE TIME: AOM <br /> f <br /> i OUT TIME: ✓'tea AM PQ <br /> i <br /> FINISH TIME:---?'QAM <br /> LOAD AMOUNT _ HAULER EXEMPTION IF APPLICABLE <br /> — �. ❑GOVERNMENT C1 LEA EXEMPT ❑OTHER <br /> AGRICULTURE Q COMMON CARRIER/BACK HAUL <br /> Q PICK UP LOAD TYPE <br /> ❑ IMPORT FROM WHOLE TIRE COV1NT Q WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑ EXPORT TO Q VOLUME CUBIC Y RDS ❑WEIGHT IN TONS <br /> I certify that under penalty of perjury under the laws of the State of California that the Informatloh provided above is true and correct.In addition,I <br /> o�Jc floro!•� am aware that falsification of this information may result In civil penalties up$25,000 per day,per violation or administrative penalties up to <br /> $5.000perviolation perday as described in Public Resources Code section 42062. <br /> � o <br /> CUSTOMER PRINT NAME CUSTO( <br /> 17ATE <br /> PLEA CIFCLE STORE LOCFSRNo. 46O8 lwm <br />