Laserfiche WebLink
OCT-04-200" THU 10:54 All COLADITRAILERISALESILLCRsPAGJDQ FAY: 2099313000 F. ��������� <br /> l ,, WILSO 4'AY1JRE CO., INC. `BEET SERVICE RECORD <br /> - u_s. r��F•sacFs TP(D 1400837. L 11 4 5 1 <br /> 9ip1 Wilson"Y Tie W&T."Way r,—Arne, 40Z'Corvrotl tMY a0`'"Wean Way 71re M21 us'"to Yaks >M�US Tits Ysfes N9Q US The Sales <br /> $ Mhty 15=Market St. 4211 M webs"Way 19"W bo.•onm SL 71600 Yasarrdte Blvd. 1915 National ova 65-0 irarrfdir Elhot <br /> Stacktan�Ca.85AW Sroekton,Co.a&" St—Aeon,am 85= Trraey,Ca.86376 Modesto,cA.a&%" Maywald Ca.A"49 Sborarnentq CA.9sB2s <br /> 2VY"5oml 2 2W 40&"l 900.835.4087 ZOS.B71,56fY 510.887.1282 81ds8d.28a5 <br /> CUSTOMER �-. /' P.O. a <br /> ✓ � � �I � l � DATE � <br /> 7_ C <br /> PHONE VE LE# <br /> 2 � <br /> LICENSE p <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID r I I �(�,—r- T-! <br /> [;;ECAC#� L�I—L t6 1a:�� <br /> I cacti that under penalty of •`•- <br /> fy p ty perJury under the laws of the State of CalifOrnia that Me information provided above is true am Cornett.In addition,1 am aware that laismoation of <br /> mis intormabon may result in suapensien,rewcation,or denial of renewal of the Waste Tire Hauler Registration pursuant to'Cubllc Resources Codc section 42960 and may <br /> result in civil penaltloa up to$2$,000 per day,per violation or administrative penalties up to 56,000 per violation per day as described In public Resources Code section 42962. <br /> DVER N <br /> RIAME DRIVE IG URE DATE <br /> N1, j TRUCI�TRAIL�L_E7R A LICENSE STATE OOOMETER/HUB <br /> rw 1 �i 1 � <br /> r�.1 <br /> SPECIAL INSTRUCTIONS <br /> OFF <br /> •OF.WORK COMPLETES! .D. ; QT . -DUCRIPPON OR'WORK dOMPLET ED,.,: OTY OESCA1PT.ON.( 1NORK CQAfPL87ED.r <br /> SERVICE GALL.,( MOUNT!DISMOUNT($)ON VEHICLE BRASS VALVE STEM($) <br /> L <br /> `- <br /> FLEET iNSPECT,JON... MOUNT/DISMOUNT(S)LOOSE ALUININUM&EM(S) <br /> AIR SERVICE MOUNT($) VALVE STEM REBUILDS) <br /> U1T REPAIR($) l''�'t <br /> ! •�C 01 OUNT(S) ALLIGATOR CAP($) <br /> REPAIR MAT``ERIAL( i. TIRE(S)BALANCED ETAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECON0,1T (S) O RINp(S) <br /> Q1r1 SIZE' MF DWORIPLLFrN(SH MILES: <br /> fSTART MILES: ti <br /> s •� <br /> TOTA.MILES: ;a <br /> -- .�.S: G' START TIME: AM PM .ffi <br /> ' ON SITE TIME: <br /> d4 :..., AM PM <br /> OUT TIME: AM PM <br /> LOAD•A#$QUNT <br /> FlNISH TIME: AM PN <br /> R EXEMPTIIPPLICASLE, <br /> ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> O AGRICULTURE ❑COMMON CARRIER/BACK HAUL <br /> LOAD:.�TYPE <br /> ❑ DELIVERY IMPORT FROM ` ;0 WHOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> D`,EXPORT TO ❑ VOLUME CUBIC YARDS Z WEIGHT IN TONS <br /> ^or I certify that under penny of perjury under the laws of fhb State Of Callfomis that the information provided above Is true and Correct.In addilion,1 <br /> ooh °T em aware that falsification of this information may result in civil penalties up to 625.000 per day,per violatlon or administrative penalties up t0 <br /> R� 55,000 per violation per day K d&scritfed in public Resources Code section 42862. <br /> CUBTOtu�B PgtNT NAMC CUSTOMER SIGNATURE <br /> FSR No. 3 4 5 r:.;�..,rte;, DATE <br />