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WILSON <br />.4Y TIRE CO., INC. <br />U.S. TIRE SALES <br />#01 Wilson Way Tire Wilson Way Tire Recap <br />#02 Connell Tire #21 US Tire Sales <br />221 N. Wilson Way 1535 Market St. <br />2211 N. Wilson Way 2600 Yosemite Blvd. <br />Stockton, CA 95205 Stockton, CA 95205 <br />Stockton, CA 95205 Modesto, CA 95354 <br />nnoe ')nn_ARK _'roa9 <br />9no-dnr.25R1 2no-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 />LICENSE # <br />LOCATION OF SERVICE <br />STATE ZIP CODE <br />CUSTOMER TPID DECAL # I1 I iP` <br />l ` + <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 <br />CUSTOMER <br />TRUCK/TRAILER # <br />DRIVER SIGNATURE DATE <br />VEHICLE INFORMATION <br />LICENSE STATE ODOMETER/HUB <br />SPECIAL INSTRUCTIONS„ , ON <br />44 <br />OFF <br />QTY. <br />DESCRIPTION OF WORK COMPLETED <br />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 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 />OUTTIME: AM PM <br />FINISH TIME: AM PM <br />LOAD AMOUNT <br />- - <br />HAULER EXEMPTION IF APPLICABLE <br />❑ GOVERNMENT <br />❑ AGRICULTURE <br />❑ LEA EXEMPT ❑ OTHER <br />❑ COMMON CARRIER/BACK HAUL <br />❑ PICK P <br />❑ IMPORT FROM -- -- - - <br />❑ DELIVERY <br />❑ EXPORTTO <br />_-_ __ - <br />LOAD TYPE <br />-- - <br />❑ WHOLE TIRE 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 />o�`c DQf°Tr 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 />eN $5,000 perviolationperdayasdescribedinPublic Resources Code section 42962. <br />w „ <br />CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />FSR No. <br />