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Joe WILSON Y TIRE CO., INC. WWI(I z'1 -7 ITWSERVICE RECORD <br /> U.S. t"IRE SALES TPID 1000837. 83265 <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 209465.3262 209-466.2581 209-8354087 209571-5611 510-887-1282 916.395-2245 <br /> CUSTOMS P.O. # DATE <br /> PHONE VEHICLE# <br /> C LICENISE# 7 // <br /> LOCATION OF SERVICESTATE [� ZIP C DE <br /> G <br /> CUSTOMER TPID C) �'- DECAL# 6 - C J- <br /> I certify that under penalty of perjury under the laws of the State of California that the in�77iaunler <br /> ti 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 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 u $5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVE IGNATURE DATE <br /> X L-:-L—6 <br /> CUSTOMER VEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> -....._._...__..........._....._._....................._.... ............_.._............_.._......................... .__.................__................_._._...................................._.._......... <br /> ........_ <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <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) 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 /> START MILES: <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> — -- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> ❑ IMPORT FROM HOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ELIVERY <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 /> ;orc Da1Q�ro 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 a described in Public Resources Code section 42962. <br /> ar <br /> ramJq - - � <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 8 �?R 5 <br />