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(VE) WILSON I ' TIRE CO., INC. /7L ET�SER CE RECORD <br /> U.S. ►IRE SALES TPID 1000837. 78755 <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 /> 209465.0281 209-465-3262 209466-2581 209-835.4087 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOM �_ P.O. # DATE / <br /> PHONE VEHICLE # <br /> ,7c �1 �. ,,3 � <br /> Q T D N A 93p27LICENS #_FZ117 <br /> LOCATION OF SERVICE STAT r ZIP CODE <br /> CUSTOMER TPID � ,��� �p � -,(� ( DECAL# <br /> b - 6o-Z. y <br /> I certify that under penalty of perjury under the lawsofthe 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$5,980 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVER SI TUBE DATE <br /> x 1 - o4 1 - ,, ,) <br /> CUSTOMER VEHICLE INFORMATION <br /> MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <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 <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 AMOU�� HAULER EXEMPTION IF APPLICABLE <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> ---- - ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP LOAD TYPE <br /> ❑ IMPORT FROM VXWHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> DELIVERY <br /> ❑ EXPORT TO ❑ VOLUME CUBIC YARDS E:1 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 /> am aware that falsification of this information may result in civil penalties to 5,000 per day,per solation or administrative penalties up to <br /> $5,000 per violation per day as described in Public Resources Code sect' n <br /> u • a <br /> a <br /> CUSTOMER PRINT NAME CUS OMER SIGNATURE DATE <br /> FSR No. 7 R 7 <br />