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- WILSON WAY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 1000837 183-119 <br /> 1101 Wilson Way Tire Wilson Way Tire Recap #01 Connell Tire #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 Nat/oval Ave. 6530 Franklin Blvd. <br /> Stockton,CA 95205 Stockton,CA 95205 Stockton,CA 95205 Modesto,CA 9$354 Hayward,CA 94545 Sacramento,CA 9581 <br /> 209-465-0281 209465.3262 209-466-2581 209-571-5611 510-887-1282 916-395-2245 <br /> CUSTOMER <br /> P.O.# DAT :' ti <br /> PHONE VEHICLE# <br /> LICENSE <br /> • V ��"-} Ll 7 1 7 j <br /> LOCATION OF SERVICES y r J! STATE ZIP CODI <br /> a (` <br /> USTO <br /> Cicertity thMatEuRTPI <br /> nderpenalty of perjury under the laws of the State of Ca DECAL# � I�'— �-�I ca <br /> lifornla 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 DIj1VE1i IGNATURE DATE <br /> CUSTOMER •R • <br /> MMAA,KE I RUCK/TRAILER# LICENSE STATE ODOME R/HUB <br /> SPECIAL INSTRUCTIO , ON OFF <br /> QTY DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED QTY. DESCRIPTION OF WORK COMPLETED <br /> (SERVICE <br /> CALL <br /> 4c1 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 /> 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 /> J <br /> _^ FINISH TIME: AM PM <br /> LOAD AMOUNT HAULER EXEMPTION IF APPLICABLE <br /> 7 0 f — ❑GOVERNMENT ❑LEA EXEMPT ❑OTHER <br /> ❑AGRICULTURE E)COMMON CARRIER/BACK HAUL <br /> O'PICK UP � <br /> LOAD TYPE <br /> ❑ IMPORT FROM •1�;1:� %t}% ��f'� �' � � � ;� .�r <br /> C3 DELIVERY D*HOLE TIRE COUNT Ll WEIGHT IN POUNDS <br /> U–EXPORT TO .?7� /1 . �;' rr r te. i' ILI VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> Doty 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 <br /> sow T�Q 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 day as described in Pubiic Resources Code section 42962. <br /> w m <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR No. $ 05/1 S A�ite' <br />