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ILSON WAY TIRE CO., INCENTERE[fLEET SERVICE RECORD <br /> U.S. TIRE SALES f TPID 1080837. 181479 <br /> re Wilson Way Pre Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> ay 1,53.5 Market SC 2211 N.Wilson Way 2600 Yosemite Blvd 1915 National Ave. 6530 Franklin Blvd. <br /> �q g Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465.3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> �+ P.O.# DATE <br /> PHONE VEHICLE# <br /> ' LICENSE# <br /> LOCATION OF SE RVI �.- STATE ZIP CODE <br /> ,�- <br /> CUSTOMER TPID �qDECAL#certify that under penalty of perjury under the laws of the State of Caiifomia that the Info n provided above is true and correct.in addition,i am aware that falsiticatlon of <br /> his information may res suspension,revocation,or denial of renewal of the re H ler Registration pursuant to Public Resources Code section 42960 and may <br /> '.result In civil penaitl p to S 5,000 per day er violation of administrative penalti s up to S 00 per violation per day as described In Public Resources Code section 42962. <br /> DRIVER NAME D IVER S ATURE DAT CUSTOMER VEHICLE INFORMATION <br /> �� /� 1 <br /> d_KE TRUCKlfRAILER# LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> QTY: DESCRIPTION OF WORK COMPLETED QTY. 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) O RING(S) <br /> PRODUCT INSTALLED <br /> QTY. SIZE MFG DESCRIP710N <br /> FINISH MILES:3 <br /> START MILE$ �� <br /> U •� TOTALMILES: <br /> y <br /> START TIME:j10,16 Ann PM <br /> ON SITE TIME:AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME::O AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> — ❑GOVERNMENT ❑LEA EXEMPT DO THEIR <br /> ❑AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> PICKUPLOAD TYPE , <br /> 11 IMPORT FROM ,5�'� ❑WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> ELIVERY <br /> ❑ EXPORT TO y j r ! SM ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I certify that under penalty of pe.rju4under the laws of the State of California that the information provided above Is true and correct.In addition,i <br /> Jop�°°4f Qr�C. 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 /> $5,000perviolation per day as described InPublIc Resources Code section 42962. <br /> I1<—Ce00 <br /> r / P"v ^ aMd r /y _'*x1 'V)1<— <br /> CUSTOMER <br /> USTOMER PRINT NAME CUSTOMER SIGNAJXRE�� DATE <br />