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C�WILSON , -AY TIRE CO., INC. <br />U.S. TIRE SALES <br />#01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales <br />221 N. Wilson Way 1535 Market St. 2211 N. Wilson Way 2600 Yosemite Blvd. <br />Stockton, CA 95205 Stockton, CA 95205 Stockton, CA 95205 Modesto, CA 95354 <br />- - 10c9 9nQ-ArR-99R1 9nQ-571-5611 <br />FLEET SERVICE RECORD <br />TPID 1000837. <br />#23 US Tire Sales #24 US Tire Sales <br />1915 National Ave. 6530 Franklin Blvd. <br />Hayward, CA 94545 Sacramento, CA 95823 <br />510-887-1282 916-395-2245 <br />CUSTOMER <br />P.O. # <br />DATE <br />PHONE <br />VEHICLE # <br />A <br />LICENSE # <br />LOCATION OF SERVICE R, <br />STATE ZIP CODE <br />CUSTOMER TPID T"I5 <br />T - <br />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 of administrative penalties up to $5,000 per violation per day as described in Public Resources Code section 42962. <br />RIVER NAME <br />DRIVER SIGNATURE DATE <br />x <br />CUSTOMER <br />VEHICLE INFORMATION <br />MAKE TRUCKITRAILER # <br />LICENSE STATE ODOMETER/HUB <br />SPECIAL INSTRUCTIONS <br />ON OFF <br />QTY. <br />DESCRIPTION OF WORK COMPLETED QTY <br />DESCRIPTION OF WORK COMPLETED <br />QTY <br />DESCRIPTION OF WORK COMPLETED <br />SERVICE CALL <br />MOUNT / DISMOUNT(S) ON VEHICLE <br />BRASS VALVE STEM(S) <br />FLEET INSPECTI IV <br />MOUNT I DISMOUNT(S) LOOSE <br />ALUMINUM STEM(S) <br />AIR SERVICE <br />LOOSE MOUNT(S) <br />VALVE STEM REBUILD(S) <br />FLAT REPAIR(S) <br />LOOSE DISMOUNT(S) <br />ALLIGATOR CAP(S) <br />REPAIR MATERIAL(S) <br />TIRE(S) BALANCED <br />METAL VALVE CAP(S) <br />WHEEL SWITCH(S) <br />RECONDITIONED WHEEL(S) <br />0 RING(S) <br />=w— <br />QTY <br />SIZE <br />PRODUCT INSTALLED <br />MFG <br />DESCRIPTION <br />FINISH MILES: <br />START MILES: <br />TOTAL MILES: <br />START TIME: AM PM <br />ON SITE TIME: AM PM <br />OUT TIME: AM PM <br />FINISH TIME: --.r AM PM <br />LOAD AMOUNT <br />HAULER EXEMPTION IF APPLICABLE <br />LIGOVERNMENT <br />—1 LEA EXEMPT ❑OTHER <br />J AGRICULTURE <br />COMMON CARRIER/BACK HAUL <br />LOAD TYPE <br />Li PICK UP <br />J IMPORT FROM <br />WHOLE TIRE COUNT WEIGHT IN POUNDS <br />❑ DELIVERY <br />J EXPORTTO <br />❑ VOLUME CUBIC YARDS J WEIGHT IN TONS <br />Icertify 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 />am aware that falsification of this information may result in civil penalties up $25,000 per day, per violation or administrative penalties up to <br />$5,000 per violation perday as described in Public Resources Code section 42962. <br />A <br />CUSTOMER PRINT NAME CUSTOMER SIGNATURE <br />DATE <br />FSR No. <br />