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WILS(11' TIRE CO., INC. 16EET SERVICE RECORD <br /> o �. TIRE SALES <br /> Z TPID 1000837. 1 7 5 416 <br /> A^, Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales 424 US Tire Sales <br /> Q.Ison Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> on,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 9-465-0281 209-465-3262 209-466-2581 209-571-5611 510887-1282 916-395-2245 <br /> CUSTOMER I � � - P.O.# DATE 5 ay <br /> PHONE VEHICLE# <br /> LICENSE# <br /> LOCATION OF SERVICE / STATE �t / ZIP CODE <br /> i <br /> CUSTOMER TPID ' �i 0 DECAL#—'D ( � <br /> pQ <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 p,&Ka ties p to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVE GNATUR DATE <br /> X `j' s 0 <br /> CUSTOMER •- • <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETERMUB <br /> �6 aoa aZs� 4c) z 30 <br /> SPECIAL IN CTIONS ON OFF <br /> � � j • _ <br /> QTY. DESCRII6bON OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> SER E CAL OUNT I DISMOUNT(S)ON VEHICBRASS VALVE STEM(S)Irl <br /> FLEET INSPECTION DOSE 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 <br /> QTY. SIZE IMFG DESCRIPTION 41 <br /> FINISH MILES: <br /> �/Q� START MILES: <br /> TOTAL MILES: <br /> C� START TIME: c� ! AM a� <br /> ON SITE TIME: AM PM <br /> OUTTIME: AM PM <br /> FINISH TIME: L/ AM PD <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT ❑LEA EXEMPT (3 OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> Ofi£K UPLOAD TYPE <br /> ❑ IMPORT FROM ,!` '� C:MHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> LJ DELIVERY <br /> p.FXPORTTO —7 ❑VOLUME CUBIC YARDS L)WEIGHT IN TONS <br /> �c DarQ 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 /> OWLiP 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 /> M $5,000 perviolation perdayas described In Public Resources Code sects 2962. <br /> R <br /> CUSTOMER PRINT NAME OMER SIGNATURE DATE <br /> FSR No. 175416 PLEASE CIRCL TORE LOCATION AT TOP <br />