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WILSO' .AY TIRE CO., INC. FLEET SERVICE RECORD <br /> . TIRE SALES ( �"�` A`�l0 ; TPID 1000837 17 5 0 0 6 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465-0281 209-465-3262 209.466-2581 209-571-5611 510-8871282 916-395-2245 <br /> CUSTOMER, P.O.# DATE <br /> PHONE VEHICLE# <br /> rAj 1A AO �ko <br /> 101 <br /> LICENSE# <br /> LOC O S VICE STAT ZIP CODE <br /> —7 <br /> CUSTOMER <br /> CUSTOMER T I '— DECAL# <br /> L , <br /> -OaN d ! ' <br /> 1 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 N DRIVER SIGNACE DATE <br /> aLaU1 X <br /> CUSTOMER • <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETERIHUB <br /> SPECIAL INSTRUCTIONS , ON _ OFF <br /> � e <br /> DEARJIFION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SER CE CALL MOUNT/DISMOUNT(S)ON VEHICLE BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TIRE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S) O RING(S) <br /> PRODUCT it <br /> QTY SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: LAI <br /> rA J0. <br /> TOTAL MILES: <br /> STARTTIME: AM M <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> r <br /> FINISH TIME: AM M <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE _ <br /> ❑GOVERNMENT O LEA EXEMPT ❑OTHER <br /> �•— ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICK UP L D TYPE <br /> ❑ IMPORT FROM - WHOLE TIRE COUNT El WEIGHT IN POUNDS <br /> DELIVERY r <br /> ❑ EXPORTTO JLJVOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty of perjury under the s of the State of California that the information provided above is true and correct.In addition,I <br /> ~op`c Dato T`o am aware that falsification of this information ay result in civil penalties up $25,000 per day,per violation o driftnistrative penalties up to <br /> _ M $5,000 per violation per day as described in Public Resources C cti 42962. <br /> ;3 <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />