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61ICR?1�0 ��, �, WILSON V4 ' TIRE CO., INC. � LEE S RV <br /> U.S. TIRE SAL8S 1W If TPID 1000837. 7 8 6 01 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #05 Wilson Way Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 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 /> 209-465-0281 209.465-3262 209.466-2581 209.8354087 209.571-5611 510.887.1282 916.395.2245 <br /> CUSTOMER P.O. # DATE c <br /> - c � <br /> PHONE VEHICLE # <br /> LICENSE# <br /> i <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID <br /> 1I �_ DECAL# <br /> VIP" <br /> I certify that under penalty of perjury 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 /> 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 SIGNATURE DATE <br /> X <br /> CUSTOMER •R • <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY. ON OF WORK COMPLETED QTY.. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT ICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNTS LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) 110, �`�; E VALVE STEM REBUILD(S) <br /> LAT REPAI - LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL 2— j TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT INSTALLED <br /> QTY. SIZE MFG DESCRIPTION FINISH MILES: <br /> A. E START MILES: <br /> TOTAL MILES: <br /> L 1 START TIME: AM M <br /> X —NIT C AnCl ON SITE TIME: AM PM <br /> ' OUT TIME: , <br /> N. (� FINISH TIME: I AM P <br /> LOAD AMOU HAULER EXEMPTION I APPLICABLE <br /> _ _ •__ ❑ GOVERNMENT ElLEA EXEMPT ❑ OTHER <br /> ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD E <br /> ❑ IMPORT FROM HOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ❑ DELIVERY <br /> ❑ EXPORT TO ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I <br /> �op�c Dora T'c am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> N $5,000 per violation per day as described in Public Resources Cade sec' 4296 VW <br /> w mX• II�.— <br /> CUSTOMER PRINT NAME CUSTO R SIGNATURE DATE <br /> FSR No. 7 Q P() 1 <br />