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22-OCT-2014 14:04 From: . 2095551212 To:B,' 783 Pa9e:5/5 <br /> 4 WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD 0(.Ptzll <br /> U.S. TIRE SALES TPID 1000837. 17 5 4 2 2 <br /> n Way TIM vfdoon my lire Recap #02 Connell Tire M US 71re Sates 023 us rde salsas 024 US Tire Sales <br /> '`Wilson Way 4535 Market 8t 2211 N.Wilson Way 260Q Yosemite Blvd, 1015 Madona/Ave. 6530 Franklin Blvd. <br /> hftn,CA 95205 Sioexior,CA 95205 Stockton,CA 96205 Mod"to,CA 45354 Hayward,CA 94545 Sataamonte,CA 9S823 <br /> 85.0481 209-/65.3262 "9466.23a1 �0.571d01t 510-087-1282 816.305-2245 <br /> CUSTOMER _ P.O.M DATE <br /> Lc 1f--S '' ` d/�° f'' <br /> PHONE VEHICLE# !' <br /> f� <br /> LlceNse# w V fig 4!3 <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID i L�j — DECAL# ) r J—�= <br /> oar*that under penalty of penury under Me Wm oNhe etste of California that the Information provided above Is true and carted.In addition,l am aware UM his' -Won of <br /> this idermstien may resutt In sugp 1won,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant b Public Resources Code sedlon'42980 and may <br /> result in civil penalties up til$25,000 per day,per violation d administrative penalties up to$5,008 per violation per day aZ described in Public Resourea Coda section 42962. <br /> DRIVER NAME oRro rURE DATE <br /> CUSTOINASK VEHICLE INFORMATION <br /> E TRUCK+Ttwil.tR it LICENSE STATE ODOMETER/HUS <br /> SPECFAI INS1RfIC9W. <br /> per,- � t•J „gyp ��. � � --_�-__-�� _.__� ___ ..^.-- <br /> Q75! <br /> N.O tV(iRlc(�QAAPI E7ED, QTY DJ:SCRI ` 'Q?Ji•':: C DE31CR1 . r3Nf?fPIEfiED <br /> SERVICE NT!DISMOUNT(S)ON VEHIC � RASS VALVE STEMS) r <br /> FLEET INSPECTION MOUNT J OISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNTS) VALVE STEM REBUILD($) <br /> FLAT REPAIRS) LOOSE DISMOUNT(S) ALLIGATOR CAP($) <br /> REPAIR MATERIALS) TIRE(S)BALANCED METAL VALVE CAPS) <br /> WHEEL SWITCH(S) RECONDITIONED WHEELS) 0 RING(S) <br /> qrY 8 :� •+I IFTit?M 'rINI$H MILES:— <br /> r> START MILES; ' <br /> 1 4,O TOTAL MILES; <br /> Jo <br /> !'Q 4 sa,,ta START TIME: 2 OL4 AM <br /> ON SITE TIME= AM PM <br /> OUT TIME AM PM <br /> FINISH TIME: A <br /> LOAD AMOUNT i lyI!ER F�� E}N IF 1?L7CfCBL ". .- <br /> L3 GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ——Q 0—— CIAGRICULTURE ❑COMMON CARRIER/6ACK HAUL <br /> PC <br /> PICK UP <br /> ❑ IMPORT FRAM ( HOLE TIRE COUNT E)WEIGHT IN POUNDS <br /> ELIP Tpt �S OLUME CUBIC YARDS ElWEIGHT IN TONS <br /> I corny that under ponaty of per)ury u r the taws of the Mote of Cilifomia that VVinformation provided above IS true and cemeol.In addition,1 <br /> 4C Datoar am aware that falsification of this iMgrmstien may result in civi:penalties up$25,000 per day,per violation or administrative ponsiUes up to <br /> $5,000 per violation per day as tivAribed in Public Resources Cedp section 42962, <br /> • <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> Celt Ain 17 9;d 9 9 ns CAcc rriOf%.l c 14Tnk;:I OCATION AT TOP <br />