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WILS A� <br /> I Y TIRE CO., INC. FLEET SERVICE RECORD <br /> U�TIRE SALES <br /> TPID 1000837• 124633 <br /> Ion, <br /> ay 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 /> n Way 1535 Market St. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> .95205 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94$45 Sacramento,CA.95823 <br /> 1 209465.3262 209466.2581 209.8354087 209.571.5611 510.887-1282 916.395.2245 <br /> USTO I P.O. # DATE <br /> > 373S <br /> PHONE VEHICLE # <br /> LICENSE# <br /> LOCATION OF SERVICE I STATE ZIP CODE <br /> 57r <br /> CUSTOMER TPID DECAL#I�1�1 <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,l 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:clvil penalti up to$25,000.per day per violation or administrative penalties up to$5,000 per violation per day as described,in Public Resources Code section 42962. <br /> DRIVER NAME D IVER SIGNATURE ATE <br /> .& <br /> CUSTOMER •- • <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS . u: " o F <br /> 9 J + <br /> E$CRIPTION OF:WORK COMPL ETE ! DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL MOUNT/DISMOUNT(S)ON VEHICLE 1?CJ i 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 /> "4TY ; = ., _T,1,, SIZE MFG DESCR/PT10(N �s �wS �,v.r .,. FINISH MILES: <br /> START MILES: <br /> _ 4 t <br /> TOTAL MILES: <br /> START TIME: /� f[�� AM P <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM' <br /> FINISH TIME: AM <br /> ®- $ <br /> LOAD AMOUNT "L {(7 ! LiC `B10, M. Mi <br /> ❑ GOVERNMENT ❑ LEA EXEMPT OTHER <br /> ----- •-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL - <br /> PICK UP <br /> ❑ IMPORT FROM / ,/)7 /Ij `�T [A WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> f -DELIVERY <br /> ❑ EXPORT TO , ; -,I/ V- 01 seo ::1 <br /> [:1 VOLUME CUBIC YARDS El WEIGHT IN TONS <br /> I certify that under penalty of perjury under the s of the State of California that the information provided above is true and correct.In addition,I <br /> oc�c Dvtq pr 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 /> S 1� <br /> $5,000 per violation per day as described in Public Resources Code section 42962. <br /> JI <br /> CUSTOMER PRINT NAME COST 46R SIGNATURE DATE <br /> FSR No. 124633 <br />