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WILSON WAY TIRE CO., INC [)FLEET SERVICE RECORD <br /> U.S. TIRE SALES ENTERE <br /> 91 z TPID 1000837 181374 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell The #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Wilson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Siva <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 <br /> 109-465-0281 209-465.3262 209 466 2581 209-571-5611 510-887-1282 916-395-2245 Hayward,CA 94545 Sacramento,CA 9; <br /> CUSTOMER P.O.# <br /> DATE <br /> PHONE VEHICLE# / <br /> LICENSE# ` �J <br /> LOCATION OF SERVICE <br /> STATE ZIP CC <br /> ----- ---------- <br /> e 2 �oLtQ <br /> ty Pthe <br /> 32 2 certify -- <br /> ICthat under PpDena�of perjury under t�laws the Sta`teJ/� DECAL# <br /> this Information may result In suspension,revocation,or denial of renewal the Waste Tire eHaultion er Registrarovided tion pursuant to Pubileove is true and co <br /> tResourcite IIIc Code section t42960 and may hat falsification of <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 NAME DRIV SIGNATURE <br /> 0 DATE <br /> MAKE •aTRUCK/TRAILER# LICENSE <br /> STATE- ODOMEYERIHUB <br /> SPECIAL INSTRUCT N <br /> ON OFF <br /> QTY W K COMPLETED q D RK QTY. DESCRIPTION OF WORK COMPLETED <br /> SERVICE C OUNT I DISMOUNT(S)ON V E BRASS VALVE STEM(S) <br /> FLEET INSPECTION MOUNT I DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILDS) <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 /> QTY SIZE MFG DESCRIPTION FINISH MILES: <br /> START MILES: <br /> r � 5 TOTAL MILES:_ f D <br /> (� v START TIME: 13 10 <br /> AM !P <br /> ON SITE TIME: AM p <br /> OUT TIME: —�—AM p <br /> FINISH TIME: AM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> ---0/ •-_ ❑GOVERNMENT ❑LEA EXEMPT OtOTHER <br /> ❑ (C <br /> A ULTURE ❑COMMON CARRIER/BACK HAUL <br /> U<CK UP LOAD TYPE <br /> ❑ IMPORT FROM <br /> ❑DELIVERY CAH )LE TIRE COUNT ❑WEIGHT IN POUNDS <br /> D-EXPORT TO <br /> ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> yc Date, I ce fy that under penalty of perjury under the laws of the State of California that the Information provided above is true and correct.In additir <br /> Joc <br /> A. a a are that falsification of this information may result in civil p les ,000 per day,per violation or administrative penalties ul <br /> f G 00 pervlo nperdayasdescribedInPublic ResourcesCode se Ion4 2. <br /> i <br /> C S E P I AM CUS E IGNA URE <br /> r DATE <br /> FSR No. 181 s 7 4 PLF:t;�SE CIRCLE STORE LOCATION A TOP <br />