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k1-201-242-3051 14:06:38 07-11-2013 7/33 <br /> t : WILSON A TIRE CO., INC. rLEET SERVICE RECORD <br /> U.S. TIRE SALES <br /> (� 15 g i g TPID 1000837. 16 5 0 2 5 <br /> Of W!lson Way Tire Wilson Way Tire Recap #02 Connell Tire <br /> 21 N.Wilson Way #21 US Tire Sales #23 US Tlre Sales #24 US Tire Sales <br /> 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> tockton,CA 952 Stockton,CA 95205 Stockton,CA 95105 Modesto,CA 95354 <br /> 09-465-0281 109 465-3T61 209.4b6-2581 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-571-5611 510-887-1282 916-395-2245 <br /> USTOMER <br /> P.O-# DATE / <br /> PHONE VEHICLE# ^ <br /> LICENSE# J <br /> SCA F SERVIC"under <br /> `Q�J STATE <br /> ^ � <br /> I certify that under aperjury CUSTOMER TPID - <br /> C/ / DECAL# ��I <br /> ry Phe 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 suspenalon,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 of administrative penalties up to$5,000 per violation per day as described In Public Resources Code section 42962. <br /> RIVER NAME DRIVER SIGNATURE DATE <br /> X <br /> WE TRUCK/TRAILER# LICENS STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS <br /> - � ON OFF <br /> 3T1 DFCRIP710ltf GtF lt+pf7j(COMPLETED QTY, DESCRIPTION OF WORK COMPLETED OTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNTS) 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 /> )7 Y - o,t,... _ <br /> --•>r <br /> MFQ Dl=SCRIPTIQN FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIM <br /> AM PM <br /> p ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: 17AM PM <br /> )AD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> —_ �^ ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP <br /> LOAD TYPE <br /> ❑ IMPORT FROM <br /> DELIVERY I a WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORTTO <br /> ❑` GLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ,c pare I certify that under penalty of perjury under the laws of the State at C III la that the Infartnatl n provided above Is true and co ecl.In addition,I <br /> ,Q rr am aware that faisiffcatlon of this Information may result Inc II ties up$25,000 y, per violation or adminiatratl a penal ies up la <br /> $5,000 par violation per day as described In Public Resource de <br /> m <br /> CUSTOMER PRINT NAME ST SIGNATOR ATE !/ <br /> SF? A C C nn c i E CIRCLE �TORE LOCATION AT TOP <br /> Received Tir1le4Jul, 11, 201 2 : 02PM No, 071 ) <br />