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1-209-242-3051 14:06:56 07-11-2013 8/33 <br /> I r WILSON TIRE CO., INC. .-LEET SERVICE RECORD 0011 <br /> U.S. TIRE SALES <br /> (0 15 o j9� TPID 1000837. 165033 <br /> 01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales <br /> #2321 N. Wilson Way 1535 Market SL 191 N>io Safes #24 F Ink Sales <br /> 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> tockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward, CA 94545 Sacramento,CA 95823 <br /> 79-465-0281 209-465-3262 209-466.2581 209-571.5611 510-887-1182 916-395-2245 <br /> JSTOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENS # 0 <br /> )CATIO F SE ICE <br /> / STATE _��/ ZIP,rCODE <br /> Z. <br /> CUSTOMER eTPID alv un the laws of the S� ECAL# VP <br /> — <br /> certify P n tY perjury tato of CaliforniaCalifomla that the Information provided p v ded above Is true and correct,in addition,1 am aware that falsification of <br /> this Informat)on may result In suspension,revocation,or denial of renewal of the Waale Tire Hauler Registration pursuant to Public Resources Coda section 42960 and may <br /> result In civil pe5"a up to$25,000 per day,per violation of administrative penalties up to$5,000 per vlotatlon per day as described In Public Resources Code section 42962. <br /> LIVER NAME DRIVER SIGNATURE DATE <br /> ✓ X <br /> • •' • <br /> \KE TRUCKITRAILER# LICENSE STATE ODOMETERIHA' <br /> ZV4 ? / <br /> ^- SEG} INSTf�UCT10N ON OFF' - <br /> ]TY. DESCRIPTION OF WORK,COII4P/_ETED QTY. DESCRIPTION OF WORK COMPLETED QTY E$CR1PT10N OF WORK COMPLETED <br /> 4 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 MATERJAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> ?1Y ``> •. MFQDES RIPTION FINISH MILES: <br /> azSTART MILES: <br /> TOTAL MILES: <br /> STARTTIME: c VAP M <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM P <br /> )AD AMOUN HAULER EXEMPTION IF APPLICABLE <br /> — ❑GOVERNMENT ❑ LEA EXEMPT i6r6THER <br /> AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOA PE <br /> ❑ IMPORT FROM <br /> DELIVERY ` HOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO �44v! / ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ,c Dalo I certify that under anally 1 perju u art law of the State of California that the Information provided above Is true and correct.In addition,I <br /> am aware that falsl calla of s 1 o all ma result In civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> $5,000 per violation day d rib In Ilc es0urcesCode section42952, <br /> S <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> G CIRCLE S-ORE LOCATION AT TOP <br /> 'SPeceived Time �Jul, 11. 20101 2 , 02 M No, 07'x. <br />