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®° WILSO ' TIRE CO,, INC. *ET SERVICE RECORD <br /> r . TIRE SALES TPID 1000837 17 6 4 9 5 <br /> a <br /> t7m ay Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 1.>>6n 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 /> 09-465-0281 209-465-3262 209-466-2581 209-571-5611 510-887-1282 916-395-1245 <br /> USTOMER P.O.# DATE !, <br /> PHONE VEHICLE# <br /> LICENSE# <br /> OCATION OF SERVICE cez' oqA STATE ZIP CODE <br /> nI ----- ----- <br /> CUSTOMER TPID 3 � b.t 6JDECAL# ( , Q <br /> ,1_ -bIZ <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 pe ties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> RIVER NAME RIV IGNATURE DATE s <br /> •(p o <br /> I <br /> CUSTOMER VEHICLE INFORMATION <br /> eAKOE pTTRUCiVTR�AIILER# LICENSE R-��-r STATE ODO <br /> �METER/HU <br /> B <br /> 'y Jib � g�J <br /> SPECIAL <br /> INSTRUCT m , ON OFF <br /> ? <br /> L <br /> QTY. D WORK COMPLETED QTY. DESCRIPTIO OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED <br /> SERVICE CAL 7OUNT DISMOUNT(S)ON VEHICL BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOON OSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) (GATOR CAP <br /> REPAIR MATERIAL(S) TIRES)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(S)4RING(S) <br /> PRODUCT INSTALLED <br /> QTY I SIZE MFG DESCRIPTION FINISH MILES: <br /> ( Zl/t04 START MILES: <br /> TOTAL MILES: 1 <br /> START TIME: A PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: ,- 1 6LO AM 16) <br /> -OAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ❑GOVERNMENT 0 LEA EXEMPT []OTHER <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> ICK UP � LOAD TYPE <br /> (3 IMPORT FROM � <br /> ❑ DELIVERY CiOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> U--F--XPORTTO a�21 r ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> Sar <br /> c pare, I certify that under penalty of perjury unde the laws of the State of California that the information provided above is true and correct.In addition,I i % 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 dayas described in Public Resources Code section 42962. <br /> 01 <br /> 01 D <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 176495 PLEASE C;RCLE STORE LOCATION AT TOP <br />