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r . WILSON 4 _ Y 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 />9nn_A99 n904 9n0 -d95 -49A9 2n9.dfifi.25R1 209-571-5611 <br />LEET 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 /a + <br />rAA 6^ <br />P.O. # <br />DATE <br />PHONE <br />VEHICLE # r <br />LICENSE # <br />LOCATION OF SERVICE <br />STATE ZIP CODE <br />CUSTOMER TPID li • , — 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 DRIVER SIGNATURE y DATE <br />INFORMATIONCUSTOMER VEHICLE <br />MAKE TRUCK/TRAILER # LICENSE STATE ODOMETER/HUB <br />SPECIAL INSTRUCTIONS , <br />ON <br />OFF <br />i I/; <br />1P 11 <br />QTY. <br />DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br />QTY. <br />DESCRIPTION OF WORK COMPLETED <br />SERVICE CALL MOUNT/ DISMOUNT(S) ON VEHICLE <br />BRASS VALVE STEM(S) <br />FLEET INSPECTION MOUNT/ 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 <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 <br />- - <br />HAULER EXEMPTION IF APPLICABLE <br />❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br />❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br />O PICK UP <br />❑ IMPORT FROM - _ - _-_- <br />❑ DELIVERY <br />❑ EXPORTTO ' <br />LOAD TYPE <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 />�or�c DotoT`P 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 />qM $5,00;µf0 perviolation perdayas described in Public Resources Code section 42962. <br />% <br />fl.?;- <br />CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />FSR No. 1 8 3 <br />