Laserfiche WebLink
oII WILSQ, WRE <br /> TIRE CO., INC. EET SERVICE RECORD <br /> ® o SALES 4 <br /> ® TPID 1000637 17 6 3 7 4 <br /> /,I Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemlte Blvd. 1915 NationalAve. 6530 Frankl/n Blvd. <br /> A 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> ,65-0281 209-465.3262 209.466.2581 209-571-5611 510-887-1282 916-395-2245 <br /> OSTOMER P.O.# DATE <br /> a , <br /> PHONE VEHICLE# <br /> LICENSE# /- ' <br /> G 0 L( 7 gel <br /> LOCATION OF SERVICE r STATE ZIP CODE <br /> I r <br /> CUSTOMER TPID L ' (� DECAL# l_!- I �—I�1.. 4-✓._.l <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 aitle p to$5,000 per violation per day as described In Public Resources Coda section 42962. <br /> DRIVER NAME DRIV IGNATURE DATE <br /> X <br /> MAKE TRUCKITRAILER# LICENSE STATE ODOMETER/HUB- <br /> J SPECIAL INSTRUC F= <br /> S ' ON OF <br /> • _..- -- -- —_._. --____. - ___. -----....._._...__......._.._..---- ...__.. <br /> Q,TY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY DE$CR(PTION'OF WW R}C'COMPCETED <br /> SERV CALL le, MO T/DISMOUNT( }ON VEHIC BRASS VALVE STEM(S) <br /> ------------------ <br /> FLEET INSPECTION MOUNT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE ST UILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) q C<I-IdATOR 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 s <br /> QTY. SIZE IMFG DESCRIPTION FINISH MILES: <br /> ` — s e) START MILES: <br /> e5e e)3 7 TOTAL MILES: <br /> START TIME: ,30 AM 19 <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: �AM <br /> LOAD AMOUNT HAULER EXEMPTION FFAPPLICAB'LE <br /> ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> 2-15'1CK UP ,l LOAD TYPE <br /> Q IMPORT FROM y6�d / <br /> ❑DELIVERY SOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> &�XRPORTTO t L fllij J Q VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> ��uaeQ I certify that under penalty of perjury under the 1 ws of the State of California that the Information provlded above Is true and correct.In addition,I <br /> Tr am aware that falsification of this Information may result In civil penalties up$25,000 per day,per vlolatlon or administrative penalties up to <br /> $5,000 per violation per day as described In Public Resources Code sectlon 42962. <br /> w o <br /> CUSTOMER PRINT NAME CU OMER SIGNATURE DATE <br /> FSR No. 17 6 3 7 4 PLEASE CIRCLE STORE LOCATION AT TOP <br />