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1-209-242-3051 14:08:58 07-11-2013 14/33 <br /> t WILSON W, _ TIRE CO., INC. AEET SERVICE RECORD (2�(I3 <br /> U.S. TIRE SALES TPID 1000837 168460 <br /> )1 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 11 N. Wilson Way 1535 Market St. 2211 N. Wilson Way 2600 Yosemite Blvd, 1915 National Ave. 6530 Franklin Blvd. <br /> 'ockton,CA 95205 Stockton,CA 95205 Stockton,CA 95105 Modesto,CA 95354 Hayward,CA 94545 Sacramento, CA 95823 <br /> 19-465-0281 209.465.3262 109-466.1581 209-571.5611 510.887-1282 916-395.2245 <br /> )STOMER P.O.# DATE <br /> PHONE VEHICLE# <br /> LICENSE# <br /> )C ON 0 SERVICE —1 STATE ZIP CODE <br /> o <br /> CUSTOMER TPID /yI / © <br /> 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 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 of administrative penalties up to$5,000 par violation per day as described In Public Resources Code section 42962. <br /> RIVER NAME J DRIVER SIGNATURE DATE <br /> X <br /> WE TRUC�ILER# LICENSE CUSTOMER VEHICILEINFORMATION STATE ODOMETER/HUB <br /> X07 - -f <br /> 7 sP,�dAp,,INS7RUG'NON5 ON OFF <br /> QTY. 0ES0RIPVCN OF WQRK COMkETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORiti-COMPL E ' <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 REBUILDS) <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 /> i <br /> OTY Io1F0.-•DDESCR1PT70N FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH T E: A P t <br /> OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> — _ ❑ GOVERNMENT ❑LEA EXEMPT THER <br /> ❑AGRICULTURE ❑ COMMON CARRIER/B K HAUL <br /> PICK UP 1-06PIVPE - <br /> ❑ IMPORT FROM WHOLE TIRE COUNT <br /> ] DELIVERY ❑WEIGHT IN POUNDS <br /> ❑ EXPORT TO 7A A ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> 1 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 /> am aware that falsification of this Inforrpatlon may result in civil penalties up$25,000 per day, per violation or administrative penalties up to <br /> $5,000 per violation perday as described In Public Resources Code section 42962. <br /> • CUSTOMER PRINT NAME', CUSTOMER SIGNATURE DATE <br /> wSo '7 velTTimQe4JGln11, 2013 2 . 02PMs=No. 0719ii L pie} LUL:' ° :`;:� ATVP <br />