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. . WILS WY TIREC .%�1�C _`LEFT SERVICE RECORD <br /> TIRE SALE , <br /> T ID 1000837 1714, 95 <br /> #01 Wilson Way Tire Wilson Way The Recap #02 Connell Ti f #21 US Tire Sales #2 S Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 15 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465-0281 209-465-3262 209 466-2581 209-571-5611 510-887-.1282 916.395-2245 <br /> CUSTOMER _ P.O.# DATE <br /> 1�08 \--I— -- lal -1 <br /> nn PHONE VEHICLE# <br /> (--ht4o LkS! 1410 <br /> LICENSE# <br /> ca q 6 VIQ . <br /> LOCAT N OF SE VICE STATE ZIP CODE <br /> CUSTOMER TPID j 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,1 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 E DRIVER SIGNA-LE DATE <br /> X <br /> CUSTOMER • <br /> MAKE TRUCK/TRAILER# LICENSE STATE ODOMETERIHUB <br /> -fg'9k- mtw— ft no A�I N� I&� <br /> SPECIAL INSTRU IONS ON OFF <br /> g4�`Iq <br /> QTY. DESCRIPTION OF WORK COMPLETED Q DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE 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) 0 RING(S) <br /> PRODUCT INSTALLED <br /> Q SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: , A !� <br /> ON SITE TIME: AM PPM <br /> OUTTIME: AM PM <br /> a FINISH TIME:A PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT ❑ OTHER <br /> •— ❑AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> PICK UP <br /> TLOADTYPE <br /> ❑ IMPORT FROM DV ! OLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> DELIVERY.❑ EXPORT TO UME CUBIC YARDS LJ WEIGHT IN TONS <br /> 1 certify that under penalty of perjury under th ws of the State of California that the information provided above is true and correct.In addition,I <br /> opc D°t°f 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 per violation per day as ciescribed in Public Resources Code section 42962. <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br />