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z.X(aOt l 3 N1 Z�'-' <br /> 4 WILSON 14 ' TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES �TPID 1000837. 78613 <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 /> CUSTOMER. P.O. # DATE _ <br /> 44-JJQ o PHONE �� p VEHICLE # 13 <br /> b/✓r'. LICENSE # <br /> LOCATION OF SERVICE t � STATE ZIP CODE <br /> 1 � Y,V1 �lv I&,(, F �® obi` <br /> CUSTOMER TPID 99 — DECAL# —L% <br /> 9 <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 /> cikt <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY. ON OF WORK COMPLETED QTY. DIN WORK CO QTY. DESCRIPTION OF WORK COMPLETED <br /> ERVICE CAL UNT/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. SIZE MFG DESCRIPTION FINISH MILES: <br /> 1 l -5 s J START MILES: <br /> TOTAL MILES: / <br /> START TIME: - U A PM <br /> ON SITE TIME: AM PM <br /> OUT TIME:MOUUP, <br /> FINISH TIME: � � <br /> LOAD AN HAULER EXEMPTION IF APPLICABLE <br /> [] GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> — • — ❑ AGRICULTURE ❑ COMMON CARRIE /BACK HAUL <br /> ICK UP LOOT PE <br /> ❑ IMPORT FROM WHOLE 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 /> roc DQIQT 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 /> $5,000 per violation per day as described in Public Resources Code section 42962. <br /> a <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 7 P r, 1 q <br />