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WILSON W - TIRE CO., INC. "- �f ��QI"SfRViCE RECORD <br /> U.S. TIRE SALES TPIQ 1000837• 89583 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #05 Wilson Way Tire 1-21 US Tire Sales ;23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1835.Market St. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,Ca.95205 Stockton;Ca.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209.465.0261 209.465.3262 209.466.2581 209.835.4087 209-571.5611 510-887.1282 916-395.2245 <br /> CUSTOMER P.O. # DATE <br /> PHONE VEHICLE# / <br /> LICENSE# <br /> LOCATION OIKSERVIC `,�/� STATE > ZIP C DE <br /> CUSTOMER TPID ` I I—�� DECAL#JJ <br /> I certifythat under penalty of P <br /> under the laws of the State of California that the information provided above is true and correct.In addition,I am aware that falsification of <br /> P Y <br /> this information may result in suspension,revocation,or denial 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 violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER <br /> IVER SIGNATU DATE C)� <br /> • •� • <br /> M /) RUCKlfRA�ILE�F , LIC $E i rTATE ODOMETER/HUB <br /> 1UnJ(�' t �llJ l <br /> PECA 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 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 INSTALLED <br /> QTY. IZE MFG) DESCRIPTION FINISH MILES: <br /> START MILES: ` <br /> TOTAL MILES: MM <br /> START TIME: V AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM P <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> — •-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UPLOAD TYPE <br /> ❑ IMPORT FROM ��' HOLE TIRE COUNT El WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑ EXPORT TO p t , (� l ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> I certify that and penalty of perjury under the laws the State of California that the information provided above is true and correct.In addition,I <br /> am aware that fal ification thi information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> $5,000 per viol per da as 2scribed in Public Resources Code section 42962. <br /> U _ <br /> W - m <br /> w <br /> USTO PRA NAME CUSTOMER SIGNATURE DATE t <br /> FSR No. 89583 <br />