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1-209-242-3051 14:05:57 07-11-2013 5/33 <br /> I : WILSON A TIRE CO., INC. FLEET SERVICE RECORD 5lqt) <br /> 17 <br /> U.S. TIDE SALES 1 5 $ TPID 1000837. 165239 <br /> O1 WI/son Way The Wilson Way Tire Recap #02 Connell Tyre #21 US 77re Sales <br /> 21 N. Wilson Way 1535 Market St. 2211 N.Wilson way #2J US The Sales #24 US The Sales <br /> tockton,CA 95205 Stockton,CA 95205 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 99-465.0181 209-465-3162 209-466-2581 109.571-5611 <br /> 510-887-1282 916.395-2245 <br /> JSTOMER P.O.# <br /> r. DATE <br /> PHONE VEHICLE# ! / <br /> LICENSE# /�� <br /> CA (/�/z r OF SE ICE X--��J <br /> STATE - IP�ODE <br /> CUSTOMER TPIDIL —I DECAL# <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�IFln of <br /> this Informs on may result In suspension,revocation,or denial of renewal of the Waste The Hauler Registration Resources Code section 42960 and may <br /> result In clvl pursuant to Public Ra <br /> Itles up to$25,000 per day,per violation of administrative penalties up to$5,000 per vlolatlon pet day as described Public Resources on 4 section 42962, <br /> :IVER NAM DRIVER SIGNATURE <br /> X DATE <br /> KE 7RUCWTRAILER# LICENSE <br /> STATE ODOMETER/HUB <br /> SCJ •-� 'L�-- t` , __. ON -.— -OFF <br /> WLi .9,4 <br /> f Tli p� TED qT�! DESCRIPTIOXII]FWORK CQMPLETED QTY OESCRIP770N 01iz yj p. <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) <br /> TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) 0 RING(S) <br /> _. _. - DESCF7 �I�N FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> STARTTIME: s A PM <br /> ON SITE TIME: Aid PM <br /> OUT TIME: AM PM <br /> FINISH TIME:' A PM <br /> AD AMOU T HAULER EXEMPTION IF APPLICABLE <br /> 1- �_ ❑GOVERNMENT ❑ LEA EXEMPT HER <br /> ❑AGRICULTURE ❑ COMMON CARRIER/BA,-CK HAUL <br /> PIC LO PE <br /> ORT FROM G <br /> DELIVERY H <br /> WOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> EXPORT TO r <br /> ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> �a"7 <br /> I certify that under penalty of perjury under the taws of the Slate of Callfomla that the Information provided above Is true and correct.In addition,I <br /> am aware that falelficalion of this information may result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> 55,000 per violation per day as described In Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> SRReceived Time J 1, 11. 2013 2: 02PM No, 0719= cIRl^.IFRTr)PI= 1nr-ATir,r,rA-r r <br />