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WILSON . ' TIR,8 CO., INC. • LEET SERVICE RECORD <br /> U.S. TIRE SALES PI D 1000837. 119620 <br /> T <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. 2211 N.Wilson Way 1133 W.Eleventh St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> 5 Stockton;Ca.95205 Stockton,Cas 95205 Tracy,Ca.95376 Modesto,CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> 209465-3262' - 209.466.2581". 209$354087 209571.5611 510-887.1282 916.395.2245 <br /> P.O. # DATE <br /> ER <br /> PHONE VEHICLE# 0 <br /> ` LICENSE# <br /> 319 �i <br /> LOCATION OF SEf#UI3F <br /> STATE ZIP CODE <br /> - DECAL# �- <br /> CUSTOMER TPID 1 � <br /> I certify that under Penalty of perjury under the laws of the State of California that the Information provided above is true and correct.In addition,I am aware that falsification of i <br /> this Information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result in civil penalties up to$Fp, Vper 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 DRIVER SIGNATURE DATE <br /> X <br /> _ LICENSE STATE ODOMETER/HUB <br /> MAKE TRU RAILER # <br /> 1. <br /> � <br /> C <br /> ��y :,.�, .•. . •SPECIAL"IfTfll %f b�1T % N I <br /> _ <br /> I <br /> l <br /> ;QFSCRI TIOI�.OF WORK COMPLETED._ , QT ` <br /> QTY. DESCRIPTION OF WORK COMPLETED QTY f <br /> SERVICE CALL I( 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) <br /> / .r ALLIGATOR CAP(S) <br /> LOOSE DISMOUNT(S) <br /> REPAIR MATERIAL(S) I r TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> z _ •s _ fJE ,GE1l aTJk� - �.: _:n FINISH MILES: <br /> START MILES: <br /> 9 <br /> �� G r S,`l1 „ 1p TOTAL MILES: n <br /> / r9 <br /> START TIME: AIAPM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> WON <br /> LOAD A <br /> ❑ GOVERNMENT ❑ LEA EXEMPT El OTHER <br /> --- -- •-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑ PICKUP <br /> ❑ IMPORT FROM ❑ WHOLE TIRE COUNT � L1 WEIGHT IN POUNDS <br /> ❑ DELIVERY ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br /> ❑ EXPORT TO <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 /> o�c Dolo�r am aware that falsification,:of this information may result In civil penalties up to$25,000 per day;per vlolatip or administrative penalties up to <br /> uo p $5,000 per violation per day as described In Public Resources Code section 42962. <br /> _m d `11 i/• 1./ I,� F f/!/-f �t% �� `'/;1 r% <br /> • -' <br /> DATE <br /> CUSTOMER <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE <br /> GCR Nn 1 1 0 rz o n _ <br />