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.EET SERVICE RECORD <br />U.S. TIRE SALES TPID 1000837WILSON VS TIRE CO., INC. CPF) <br />#01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire <br />221 N. Wilson Way 1535 Market St. 2211 N. Wilson Way <br />Stockton, CA 95205 Stockton, CA 95205 Stockton, CA 95205 <br />�no�a5_n2R1 209-465-3262 209-466-2581 <br />CUSTOMER <br />#21 US Tire Sales <br />2600 Yosemite Blvd. <br />Modesto, CA 95354 <br />209-571-5611 <br />P.O. # <br />PHONE <br />#23 US Tire Sales <br />1915 National Ave. <br />Hayward, CA 94545 <br />510-887.1282 <br />DATE / .� <br />.:_� <br />VEHICLE #' <br />LICENSE If <br />#24 US Tire Sales <br />6530 Franklin Blvd. <br />Sacramento, CA 95823 <br />916-395-2245 <br />STATE 7 -IP CODE <br />LOCATION OF SERVICE <br />;;�' ,�' ,'� a � ter~ �,%����i.�•' i. V J <br />r ,/ E p <br />-Jf <br />i <br />DECAL # Ir <br />CUSTOMER TPID 't� i t <br />on provided this certify that under <br />may resuof lt in perjury <br />suspeunder <br />the laws <br />a revocation, the <br />State of enial of California <br />of the Waste rmati Hauler Registration pursuant to Public is true and tR Resources Code section . in addition, I am aware t42960 hat falsification <br />may of <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 DATE Resources Code section 42962. <br />DRIVER SIGNATURE <br />DRIVER NAME X <br />MAKE <br />TRUCKIFTRAILER # <br />ESPECIAL INSTRUCTIONS <br />DESCRIPTION OF WORK COMPLETED <br />MOUNT / DISMOUNT(S) ON VEHICLE <br />MOUNT / DISMOUNT(S) LOOSE <br />LOOSE MOUNT(S) <br />LOOSE DISMOUNT(S) <br />TIRE(S) BALANCED <br />RECONDITIONED WHEEL(S) <br />LICENSE STATE <br />ON <br />QTY DESCRIPTION OF WORK COMPLETED <br />SERVICE CALL <br />FLEET INSPECTION <br />AIR SERVICE <br />FLAT REPAIR(S) <br />REPAIR MATERIAL(S) <br />WHEEL SWITCH(S) <br />SIZE <br />LOAD AMOUNT <br />❑ PICK UP <br />❑ IMPORT FROM <br />❑ DELIVERY <br />❑ EXPORTTO <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 perviolation per day as;Aescribed in Public Resources Code section 42962. <br />_ _— -- — -- DATE <br />CUSTOMER SIGNATURE <br />CUSTOMElk FORINT NAMFof <br />QTY. <br />ODOMETER/HUB <br />OFF <br />QTY DESCRIPTION OF WORK COMPLETED <br />BRASS VALVE STEM(S) <br />ALUMINUM STEM(S) <br />VALVE STEM REBUILD(S) <br />ALLIGATOR CAP(S) <br />METAL VALVE CAPS) <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 />_HAULER EXEMPTION IF APPLICABLE <br />❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br />❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br />LOAD TYPE <br />(� WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br />r� ❑ VOLUME CUBIC YARDS ❑ WEIGHT IN TONS <br />CCQ Nin <br />