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J/2 3� <br /> oil WILSON V Y TIRE C,,WC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837. 78543 <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 209.835.4087 209.571-5611 510-887.1282 916-395.2245 <br /> CUSTOMERP.O. # DATE <br /> PHONE VEHICLE # e� <br /> LICENSE# G <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> TQV _ ? <br /> certify �TPIOnaI of perjury under the laws of the ST.- <br /> CUSTOMER <br /> f California that the information provided above is true and correctAL .In��t� � v� � <br /> penalty p l ry p n,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 12 i -0-i� <br /> CUSTOMER VEHICLE INFORMATION <br /> MAKE TRU RAILER # LICENSE ST TE ODOMETER/HUB <br /> L 7 <br /> SPECIAL INSTRUCTIONS ON OFF <br /> ---------------_...-----...._._..___........ <br /> --- ...... <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHIC QPRASS VALVE STEM(S) <br /> FLEET INSPECfION 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. SIZE MFG DESCRIPTION, FINISH MILES: <br /> — " r START MILES: <br /> TOTAL MILES: <br /> START TIME: M <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: A P <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> -- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP I LOAD TYPE <br /> ❑ IMPORT FROM HOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> 1DELIVERY <br /> ❑ <br /> ❑ EXPORT TO Z VOLUME CUBIC YARDS [I WEIGHT IN TONS <br /> tha'u ndepenalty of perjury under the I s of the State of California that the information provided above is true and correct.In addition,I <br /> roc D°to w re thaal ification of this information y result in civil penalties up to$25,000 per day,per violation or administrative penalties up to <br /> viol ti n per day as described i ublic Resources Code section 42962. <br /> w m <br /> C ST ME h PR T NAM CUSTOMER SIGNATURE DATE <br /> FSR No. 7 0 r A <br />