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,. , WILSON <br />AY TIRE CO., INC. <br />- ' <br />U.S. TIRE SALES . <br />#01 Wilson Way Tire <br />Wilson Way Tire Recap <br />#02 Connell Tire #21 US Tire Sales <br />221 N. Wilson Way <br />1535 Market St. <br />2211 N. Wilson Way 2600 Yosemite Blvd <br />Stockton, CA 95205 <br />Stockton, CA 95205 <br />Stockton, CA 95205 Modesto, CA 95354 <br />209-465-0281 <br />209-465-3262 <br />209-466-2581 209-571-5611 <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 i �'(/ <br />P.O. # <br />DATE J r <br />� .✓ 1" <br />�✓� � '✓/ 4'"°.' Y tri �+. ,/'��j- , ,.�/,4- <br />"p } 1�,. <br />PHONE <br />VEHICLE # <br />7 <br />LICENSE # <br />LOCATION OF SERVICE <br />STATE ZIP CODE <br />CUSTOMER TPID�I <1 �� -I1 1�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 />DRIVER NAME ti t DRIVER SIGNATURE' J � +`w j r' % DATE <br />) <br />CUSTOMER•' • <br />MAKE TRUCK/TRAILER# LICENSE STATE ODOMETER/HUB <br />SPECIAL INSTRUCTIONS ' ON <br />OFF <br />QTY. <br />DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br />QTY. <br />DESCRIPTION OF WORK COMPLETED <br />SERVICE CALL MOUNT I DISMOUNT(S) ON VEHICLE <br />BRASS VALVE STEM(S) <br />FLEET INSPECTION MOUNT I DISMOUNT(S) LOOSE <br />ALUMINUM STEM(S) <br />AIR SERVICE LOOSE MOUNT(S) <br />VALVE STEM REBUILD(S) <br />FLAT REPAIR(S) LOOSE DISMOUNT(S) <br />ALLIGATOR CAP(S) <br />REPAIR MATERIAL(S) TIRE(S) BALANCED <br />METAL VALVE CAP(S) <br />WHEEL SWITCH(S) RECONDITIONED WHEEL(S) <br />O RING(S) <br />QTY. <br />SIZE <br />PRODUCT INSTALLED <br />MFG 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 r <br />HAULER EXEMPTION IF APPLICABLE <br />❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br />- - • <br />❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br />PICK UP <br />LOAD TYPE <br />❑ IMPORT FROM <br />❑ WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br />❑ DELIVERY <br />❑ EXPORT T <br />❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br />�o �c vafo T`o <br />m <br />w m <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, <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 perviolation per day as described in Public Resources Code section 42962 <br />{ <br />CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />FSR No. <br />