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W.IL N, Y TIRE CO., INC. FLEET SERVICE RECORD <br /> U - . IIE SALES • TPID 1000837 <br /> . 122 $8 <br /> Uson802 Connell Tire 805 Wilson Way Tire X21 US Tire Sales 823 US Tire Sales #24 US Tire Sales <br /> §M <br /> t <br /> 1535: } 'tlftiWilson t y 1133 W.Eleventh'St. 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> r` <br /> 3 Stoa", � �5. 5` Tracy,Ca.95376 Mgdesp CA.95354 Hayward,Ca.94545 Sacramento,CA.95823 <br /> A EC„ <br /> 209 ;0R-835-4087 <br /> 1 510-887.1282 916.395.2245 <br /> EF} s!t P.O. # 3g ft ?1= DATE <br /> A <br /> PHONE VEHICLE # . <br /> LI EN E# <br /> LOCATION OF SERVICE I' STATE; `,�" ZIP CODE <br /> L <br /> CUSTOMER TPID — 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 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$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME :c. a. DRIVER SIQNATURE ,",ATE ,) <br /> CUSTOMER •- • <br /> MAKE ( TRUCK-7 # LICENSE STAT ODOMETrRLH B <br /> _._ t Li A. <br /> ",. ff � �� SFECIALJ+NSTRUC t <br /> pet,:? <br /> f , <br /> '� ::DESCRIPTION OF WORE i% 1�1P C7m4r s. t"? (� 71f9 l%V1WOfik C,DMP�E M -,i r° <br /> DIsom- AMR M& <br /> SERVICE CFJLL­- OLINT/ I�Q�f�($a�J J 1LF.�OJ j� � 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 INSTAUED <br /> QTY; - SIZE- :" MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> 7 <br /> �t �� [7f START TIME: . `AMPM <br /> ON SITE TIME: AM PM <br /> JALI <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> NN 12-LOAD AMOUNT . . � <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> ----- •-- ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> ❑ PICKUP LOAD TYPE.", <br /> ❑ IMPORT FROM ❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> ❑ DELIVERY <br /> ❑ <br /> ❑ EXPORT TO VOLUME CUBIC YARDS EJ 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 /> `gc�c DaIQTr 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 /> �j $5,000 per violation per day as described In Public Resources Code section 42962. <br /> ate, • + '`tet t\ ...--.-.+•' _ - <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE ~ DATE <br /> FSR No. 1 2088 <br />