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WILSON WAY TIRE CO., IN�NTERED I`LPET SERVICE RECORD <br /> U.S. TIRE SALESAe TPID 1OQQ837- 184606 <br /> #of Wiison Way Tire Wiser;Way Tire Recap 902 Connell Tire #21 US Yre Salas #24 US The Sales #24 US Tire Sales <br /> 221 N.Wlison Way 1535 Market St. 2211 N.NWson Way 2600 Yosemite Blvd, 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 9582. <br /> 209-465.0281 209.465.3262 209.466.2581 209.571.5011 514.887-1282 916-395.2245 <br /> CUSTOMER P.O.# DAIE _ <br /> � <br /> PHONE VEHICLE# <br /> 7-1 <br /> LICENSE# <br /> 4.lC�d� <br /> LOCATION OF SERVICE <br /> STATE ZIP CODE <br /> i <br /> CUSTOMER TPID t I DECAL 1) I — <br /> I certify that under penalty of perjury under the laws of the Stale of California that the Information provided above Is true and correct.In addition,l am aware 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$25,000 per day,per vlolatlon of administrative penalties up to$5,000 per violation per day as described in Public Resources Coda section 42952. <br /> DRIVER NAME DIVER SIGNATURE--, DATE I —1 <br /> 11,11FORNIATIOiN <br /> MAKE /� r TRUCKITRAILER# LICENSE STA OOOMETERIHUB <br /> Y `/ / 9t�1�>77 CLQ- o Y117 <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF IWRK 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 /> AIR SERVICE LOOSE MOUNTS) 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 RINGS} <br /> PRODUCTa <br /> Ory. SIZE MFG DESC7P- 10N FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> STARTTIME:QQ _CV) PM <br /> ON SITE TIME: V4PM <br /> OUTTIME: 33-0 -.a <br /> FINISH TIME:—3 5'f AM M <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ——�• — ❑GOVERNMENT O LEA EXEMPT ; ❑OTHER <br /> AGRICULTURE Q COMMON CARRIERIBACK HAUL <br /> ❑PICK UP LOAD TYPE <br /> ❑ IMPORT FROM haWHOLE TIRE COLINT ❑WEIGHT IN POUNDS <br /> gQ DELIVERY ff <br /> 0 EXPORTTO VOLUME CUBIC YBIRDS Q WEIGHT IN TONS <br /> `I cg yify that under penalty of per)ury under the laws of the Stale of California that the informatlor}provided abova Is true and correct.In addition,I <br /> oo�c Oe1oP am aware that falsification of this information may nesutl In civil penalties up$25,000 per day,per violation or administrative penalties up to <br /> J Q� <br /> $s,00o per violation per day as described in Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR N0. 184606 PLEASE CIRCLE STORE LOCATION AT TOP <br />