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oil2" <br /> WILSON I ' TIRE CO., INC. C '7 FTEZIERVICE RECORD <br /> U.S. iiRE SALES TPID 1000837. 78756 <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 209-465-3262 209.466-2581 209-835-4087 209-571.5611 510.887.1282 916-395-2245 <br /> CUSTOME L !bn P.O. # DATE y ! y <br /> i PHONE VEHICLE #1 <br /> 37 <br /> LICENSE # <br /> 1 Gp Glace G <br /> LOCATION OF SERVICE STAT/.A ZIP.Q,ODE <br /> CUSTOMER TPID DECAL# f� - © 6 <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$25,000 per day,per violation or administrative penalties up to$ , 00 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME gi ,/ DRIVER S ATURE DATE I O� <br /> N G x -- <br /> CUSTOMER VEHICLE INFORMATION <br /> MAKE TRUCKITRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <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) IRE(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 /> Ti ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ICK UP LOAD TYPE <br /> ❑ IMPORT FROM OLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> DELIVERY _ <br /> �- /4 Q ❑ VOLUME CUBIC YARDS El WEIGHT IN TONS <br /> El EXPORT T2153_.5' <br /> I certify that under penalty of perjury un J.the laws of the State of California that the information provided above is true and correct.In addition,I <br /> .os;,c DQIQ�rQ 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 /> oN $5,000/e�r vio`art'io(n- r day as/described in Public Resources Code sect' 2. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 7R75G <br />