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IL S iA(AY TIRE CO., INC. FLEET SERVICE RECORD <br /> L. TIRE SALES TPID 1000837. 12 4 5 4 9 <br /> Wilson Way Tire Recap #02 Connell Tire +#05 Wilson Way Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 1535 Market St. 22f f N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> 5 Stockton,Ca.95205 Stockton,Ca.95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.9582: <br /> 209.465.3262 209.466.258.1' 209.835.4087 .209.5715611 510x887.1282 916.395.2245 <br /> ER ,}r',—� P DATE <br /> j <br /> PHONE VEHICLE # <br /> LICENSE # <br /> LOCATION OF SERVICE _ / STATE ZIP CODEC <br /> l y' <br /> , <br /> CUSTOMER TPID I — DECAL# <br /> i} I certify that under penalty of perjury under the laws of the State of California that the informationprovided 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 uy.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 NAMEDRIVER SIGNATURE 'DATE <br /> /l <br /> CUSTOMER VEHICLE INFORMATION <br /> I- -..,� Y ..s:.•w,r.:v-AYr'..�.<.-.k'�°Y '.,.i..i"G� ...W:, .��. M__yy�:}:.,, J <br /> MAKE TRUCRAILEP7i f�?� LICENSE STATE'S ODOMETeR/H.UB--- <br /> >' ' em <br /> SPECIAL INSTRUCTIONS. =: ' F� <br /> r ----- <br /> A/r, <br /> C� DE ?IPTIURK ..P1 ET-P�+ QTY,;; DES4� 14.., N F yVU7 EQfy E%J S fl O .QF;N/ORKGOMPLETED <br /> SERVICE CAL MOUNT/DISMOUNT(S)ON VEHICLE --43RASS VALVE STEM(S) <br /> FLEET INSPECTION_ MOUNT/DISMOUNT(S)LOOSE ; A UMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNTS) : VALVE STEM REBUILD(S) <br /> FLAT REPAIRS) Z_ (a LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> j REPAIR MATERIAL ' `/f'� TIRE(S) BALANCED METAL VALVE CAP(S)' <br /> ' WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT <br /> INSTALLED FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> `i START TIME: AM <br /> (PM <br /> ON SITE TIME: AM PM <br /> is <br /> OUT TIME: AM PM <br /> FINISH TIME ! J �— AM;PM <br /> LOAD AMOUNTa.:. _ HAULER EXEMPT-10�} IF APPLICABLE « <br /> ❑ GOVERNMENT _— ❑ LEA EXEMPT ❑ OTHER <br /> G ----- -- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑ PICKUP L''OAD' 1CPE .; <br /> ❑ IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ❑ DELIVERY <br /> El EXPORT TO EJVOLUME CUBIC YARDS El 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 /> �,c Datq,p 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 as described in Public Resources Code section 42962. <br /> w m <br /> h- <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> ` FSR No. 124549 <br />