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'. Vit, WILSON Ali TIRE CO., INC. <br />U.S. TIRE SALES <br />#01 Wilson Way Tire Wilson Way Tire Recap !i #02 Connell Tire #21 US Tire Sales <br />221 N. Wilson Way 1535 Market St. 1 2211 N. Wilson Way 2600 Yosemite Blvd. <br />Stockton, CA 95205 Stockton, CA 95205 Stockton, CA 95205 Modesto, CA 95354 <br />209-465-0281 209-465-3262 209-466-2581 209-571-5611 <br />FLEET SERVICE RECORD <br />TPID 1000337• A. 5 0 13 7 <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 />tib �• �, V 4'� f t�� � �!C �t�`'f' <br />P.O. # <br />DATE <br />� p'/ � `,� ,� <br />PHONE <br />VEHICLE # J <br />i (f <br />LICENSE # sJ <br />LOCATION OF SERVICE/ s ,1`j <br />STATE ZIP CODE <br />CUSTOMER TPID I' f DECAL # I / q <br />�I 51 <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 />a <br />DRIVER NAME <br />! <br />CUSTOMER•' <br />MAKE TRUCK/TRAILER # <br />DRIVER SIGNATURE_ _ DATE } } <br />• <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 INSPECTION <br />MOUNT / 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 />O RING(S) <br />QTY. <br />SIZE <br />PRODUCT <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: AM PM <br />LOAD AMOUNT <br />— — — • — — <br />❑ GOVERNMENT <br />❑ AGRICULTURE <br />HAULER EXEMPTION IF APPLICABLE <br />❑ LEA EXEMPT ❑ OTHER <br />❑ COMMON CARRIER/BACK HAUL <br />PICKUP _t_ <br />LJ IMPORT FROM # �o.F- Ak';1 ' l" �``tr1f -' <br />❑ DELIVERY F e <br />❑ ExPORTTO-" : fir. ,f.. <br />LOAD-TYP <br />U WHOLE COUNT ❑ WEIGHT IN POUNDS <br />❑VOLUME CUBIC YARDS ❑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 />oo�c Dafp T 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 />oY $5,000 per violation perday a9 described in Public Resources Code section 42962. <br />d / <br />CUSTOMER i2 : A,jCUSTOMER SIGNATURE DATE <br />FSR No. 150137 <br />