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r. WILSON V& 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 />209-465-0281 209-465-3262 ! 209-466-2581 209-571-5611 <br />.EET 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 li l <br />PHONE <br />VEHICLE # <br />LICENSE # <br />LOCATION OF SERVICE <br />STATE,r' y f% y ZIP CODE <br />- <br />�.. <br />CUSTOMER TPID! T <br />— <br />DECAL # Is j <br />I certify that under penalty of perjury under laws of the State of California <br />that the information provided�aliove is true and correct. In addition, I am aware that falsification of <br />this information may result in suspension, revocation, or denial of renewal <br />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 />DRIVER NAME <br />i <br />DRIVER SIGNATURE 4Y, -f i:DATE Ml <br />X <br />CUSTOMER <br />•' <br />MAKE TRUCK/TRAILER # <br />LICENSE STATE ODOMETER/HUB <br />SPECIAL INSTRUCTIONS <br />, <br />ON OFF <br />t <br />QTY. 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 SIZE <br />PRODUCT INSTALLED <br />MFG <br />DESRIPTION <br />C <br />FINISH MILES: <br />START MILES: <br />TOTAL MILES: <br />STARTTIME: AM PM <br />ON SITE TIME: AM PM <br />OUT TIME: AM PM <br />FINISH TIME: AM PM <br />LOAD AMOUNT <br />HAULER EXEMPTION IF APPLICABLE <br />❑ GOVERNMENT <br />❑ LEA EXEMPT ❑ OTHER <br />— — • — <br />❑ AGRICULTURE <br />❑ COMMON CARRIER/BACK HAUL <br />PICK UP <br />LOAD TYPE <br />❑ IMPORT FROM <br />[] WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br />❑ DELIVERY <br />❑ EXPORT TO <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 alcove is true and correct. In addition, I <br />oo'c Dotq r am aware that falsification of this information may result in civil penalties up $25,000 per day, per violatl'on or administrative penalties up to <br />oN $5,000 per violation per day as described in Public Resources Code section 42962, <br />a <br />od 111 1 / <br />CUSTOMER PRINT NAMTTT— CUSTOMER SIGNATURE DATE <br />FSR No. ° <br />