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C�WILSON V Y TIRE CO., INC. <br />U.S. TIRE SALES <br />#01 Wilson Way Tire Wilson Way Tire Recap <br />221 N. Wilson Way 1535 Market St. <br />Stockton, CA 95205 Stockton, CA 95205 <br />209-465-0281 209-465-3262 <br />#02 Connell Tire #21 US Tire Sales <br />2211 N. Wilson Way 2600 Yosemite Blvd. <br />Stockton, CA 95205 Modesto, CA 95354 <br />209-466-2581 209-571-5611 <br />"LEET SERVICE RECORD <br />TPID 1000837. 150341 <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 />V'J <br />P.O. # <br />DATE <br />PHONE <br />VEHICLE # <br />LICENSE # <br />LOCATION OF SERVICE <br />IV I <br />STATE ZIP CODE_ I <br />7— <br />CUSTOMER TPID J DECAL# f <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 penaltlids2op to $2 5,000 per day, per violation of administrative penalties up to $5,000 per violation per day as described in Public Resources Code section 42962. <br />I <br />' <br />DRIVER NAME DRIVER SIGNATURE nx DATE <br />x <br />CUSTOMER VEHICLE INFORMATION <br />MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br />SPECIAL INSTRUCTIONS ON <br />OFF <br />QTY <br />DESCRIPTION OF WORK COMPLETED <br />QTY 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 I DISMOUNT(S) LOOSE <br />ALUMINUM STEM(S) <br />AIR SERVICE <br />FLAT REPAIR(S) <br />LOOSE MOUNT(S) <br />VALVE STEM REBUILD(S) <br />LOOSE DISMOUNT(S) <br />ALLIGATOR CAP(S) <br />REPAIR MATERIAL(S) <br />TIRE(S) BALANCED <br />METAL VALVE CAP(S) <br />QTY <br />WHEEL SWITCH(S) <br />SIZE MFG <br />RECONDITIONED WHEEL(S) <br />'WROA� — <br />DESCRIPTION <br />0 RING(S) <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 HAULER EXEMPTION IF APPLICABLE <br />❑ GOVERNMENT J LEA EXEMPT J OTHER <br />J AGRICULTURE J COMMON CARRIER/BACK HAUL <br />LOAD TYPE <br />Fj'PICK UP <br />U IMPORT FROM Lj WHOLE TIRE COUNT J WEIGHT IN POUNDS <br />❑ DELIVERY L) VOLUME CUBIC YARDS J WEIGHT IN TONS <br />F I EXPORT TO <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 />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 per day as described in Public Resources Code section 42962. <br />• CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />FCR Nn 1 i;n'JA1 <br />