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• , , WILSON WAY TIRE c0., I . L)S <br /> ERVICE RECORD . . r <br /> .�� U.S. TIRE SALES <br /> 000837• 18 4 61 <br /> ,/son Way The WUson Way Tire Recap #02 Connell Tire #21 USre Safes #24UST/reSales t. <br /> A Wilson Way 1535 Market St. 2211 N.W lson Way 00 YonalAve. 6530 Franklin Blvd. <br /> ,ockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Mor CA 94545 Sacramento,CA 95823 <br /> 49.463-0281 209-46S-3262 209.466.2581 209.571-5611. 510-887-1282 - 918-395.2245 <br /> CUSTOM � P,O.# DATE <br /> PHONE VENICE #INN '7 <br /> '%z LICENS # <br /> LOCATION F SERVICESTATE ZIP CODE <br /> GUSTOMER7PID J ;8 a y O S�— QECAL# —CV�J�LI-- <br /> 1 certify that under penalty of parjury under the laws of the State of California that the information provided above Is true and correct.In'addltlon,I am awate That falsification of <br /> this Information may result In suspension,revocation,or denial ofrenewal 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 violation of administrative penalties up to$5,000 pe ation per day as described In Public Resources Code section 42952. <br /> DRIVER NAME DRIVER SIGNATUR ATE <br /> CUSTOMIER VEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER# <,(r. LICENSE STATE DOMETER/HUB <br /> Ot 7 7tv, - - - --- ---- <br /> TY DESCRIPTION OF WORK COMP,LEVO. VTY. ,- GRIP i7 CITY OESQRJP71ON bF.WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE A MINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) 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 RING(S) <br /> PRODUCT <br /> �. FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> STARTTIME:�,`�' ° AMg- <br /> �r <br /> ION SITE TIME:' AM�A{1 <br /> OUT TIME: AMV•- - <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLIC'A8 IE • _ <br /> , ©GOVERNMENT ❑LEAEXEMPT L]OTHER <br /> - --- � ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ❑PICKUP • ' <br /> Q IMPORTFROMWHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> QDELIVERY <br /> ✓ ❑ EXPORT TO L ❑VOLUME CUBIC YA DS LJWEIGHT IN TONS <br /> 4ertify that under penalty of perjury under the laws of the State of California that the Information provlded above Is true and correct.In addttion,I <br /> aopv°Doig P� 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 /> $51000 perviolation per day as described In Public Resources Coda section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE' DATE <br /> FSR N0. 184612 PLEASE'CIRCLE STORE LOCATION.AT TOP <br />