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� 1 <br /> WILSON Y TIRE CO., INC. �l QT SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837. 83263 <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 /> CUSTOM P.O. # DATE L <br /> I G 6,Q <br /> PHONE VEHICLE# <br /> '1 1 1.A c,L� ,D i` �o�✓.� �✓ <br /> LICENSE # <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID 3 b — 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 Redistration 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$5,000 r violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER <br /> IVER SIGNA E DATE J D J <br /> CUSTOMER • (Ci <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) 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 /> .11 ICK UP L AD TYPE <br /> ❑ IMPORT FROM HOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> DELIVERY {._ J El VOLUME CUBIC YARDS WEIGHT IN TONS <br /> El EXPORT TO s?'�IYV <br /> I certify that under penalty of perjury 4der the laws of the State of California that the information provided above is true and correct.In addition,I <br /> `o��c Daly TrV 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 /> N $5,000 per violation per day as described in Public Resources Code sect' 42962. <br /> w . m <br /> r / //�n4 <br /> Al �� l� GhJ � <br /> CUST MER PRINT 6AME CUSTOMER SIGNA46RE DATE <br /> FSR No. ---- <br />