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WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837' 1801917 <br /> #01 Wilson Way Tire Wilson Way Tire Recap #02 Connell Tire #21 US Tire Sales #23 US Tire Sales #24 US Tire Sales <br /> 221 N.Wilson Way 1535 Market St. 2211 N.Mlson Way 2600 Yosemite Blvd. 1915 National Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 95354 Hayward,CA 94545 Sacramento,CA 95823 <br /> 209-465-0281 209-465-3262. 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER P.O.# DATE <br /> PHONE f HI # <br /> LICENSE# <br /> LOCATION OF SERVICE �j STATE ZIP CODE <br /> r v <br /> CUSTOMER TPID DECAL# 3 <br /> 1 certify that under penalty of perjury underthe 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 penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. <br /> DRIVER NAME DRIVk�pp',SIGNATUR DATE rr <br /> CUSTOMERINFORMATION <br /> MAKE TRUCKlfRAILER# LICENSE STATE ODOMETERIHUB <br /> SPECIAL INSTR C IONS , ON OFF <br /> �. �._ ;• � -sem�/�/ • --- . _ _ _ ___ <br /> QTY. RESCR/P.,ZIQN OF WORK COMPLETED QTY. DESCRIPTIO K COMPLETED QTY DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL' ---7 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 DESCRIPTION FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: AM PM <br /> ON SITE TIME: AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> r 1 __ ❑GOVERNMENT ❑LEA-EXEMPT ❑OTHER <br /> (JAGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> UrPICK UP LOAD TYPE <br /> C) IMPORT FROM ( � I rrlef I j-- <br /> E)DELIVERY u\WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> a-EXPORTTO �i �( l I c ( � i ; �� ❑VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> Date I certify that under penalty of perjury under tAe laws of•the State of California that the inform atlon provided above Is true and correct.in addition;i.r <br /> Aomod` Ae am aware that falsification of this Information may result in civil penalties up$25,000 per day,per violation or administrative penalties u`p Ta <br /> � G $5,000 perviolation perdayasdescrIbed In Public Resources Code section 42962. <br /> 1,t-. —. <br /> CUSFOM ERPRINT NAME u CUSTOMER SIGNATURE DATE <br /> FSR NO. 180917 71415 g . <br />