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DST-04-2007 THU 10:51 APS V7ADITRAIIEP,ISA1ESlhICRsPAGJIIQ FAv:2099313C�00 P. <br /> w WILSOF 'AY TIRE CO., INC. FLEET SERVICE RECORD <br /> U.a. TIRE SALES 1 5,,�27/(�o TPID 1000837• 96524 <br /> n01 wikon Way 77M whson Way T*V Ree1P 002 tbMerl Tire #05 Wfton Way Tisa 421 us TGe Setae 029 US r—Sales sax trs Tire gates <br /> 221 N.W.faon Way 1999 A{arket SL 2811 N,tvifson Way 1133 W.Efoverfm St 2600 Yosemite Blvd 1914 National Ave, 66,70 Frankiki gale, <br /> Stoektor6 Ca.95205 stocktor4 Ca.952D5 S'! 4nor/,Ca.gums rMay,ca.95376 Al*~*,CA 8Y95t Naywaad,Ca.94545 ?acramentq CA.95823 <br /> Zo94654=1 20846S32GY 209-466-2551 209.e76.0W7 $QS671667f 510.687.1282 974•$8'.i2�Id <br /> 'CUSTOMER �-- P.O.# DATE <br /> PHONE VEHICLE f11 <br /> LICENSE l3 <br /> 7C1C <br /> LOCATION OF SERVIC�i STATE ZIP CODE <br /> Y �c'J '�..1/� '. <br /> Ir 1 �� DECAL ,} <br /> CUSTOMERTPID ...._j. ..>L_L..1�I—J—L—L� s r_�iG f'� 0,0�o�.d <br /> I certify that under penalty of perjury under the laws of the State of California that the informationv l <br /> pro idtd above is true and correct In addition,t im avrare that falsification of <br /> this Information may result in suspension,revocation,Or denial of renewal of the Waste Tke Hauler Registration pursuant to public Resources Code wettipn 42960 and may <br /> result In civil )ilea up to 325,DDD-w day,Ar Y#4tion or administrative penalties up to 95,000 per violation per day as described in public Reseurees Code section 42962. <br /> DRIVER NAtulq J DRIVER SIGNATU ! , Bim` <br /> ti. i-�iL� _.ti_.• X .{ ,tet.t \4,tL..fir A�2!,!/;.;.� <br /> MAKE TRUCKlfRA1LER:i1 LICENSE STATE ODOMETER/HUS <br /> IAL iNST. TIO <br /> QTY. DESCRIPTION-OF WORK.CQMRLfTED; 1 `; DES ON OFIN�f1K' LF,TEO ,'�.,: QTY ? IDESCATPTICJV:OF;WpRKCOMPLE�Q .' ..'•. <br /> SERVICE CALL MOUNT 1 DISMOUNT(S).ON v�f�fEI.E V'�.5+ y r #A$ JAtAiE�S7Elvf(S) � <br /> FLEET INSPECTION MOUNT!DISMOUNT(S)LOOSE . `, '� ALUMINUM STEM(S), <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEMA EqUtLO(S <br /> FIAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL{S} 'T (S)SALANCEQ METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) gECOI OITIONED WMEEL(S) O RING(S) <br /> SIZE MFG' DESCRIPrON FINISH MILES: <br /> START MILES: <br /> TOTAL MILES: <br /> START TIME: AM Pm <br /> ON SITE TIME: AM Ptd <br /> OUT TIME' AM PM <br /> FINISH TIME: AM Pin <br /> LOAD AMOUNT HAULER-EXEMPTI N.I£APPLICABLE .; <br /> D GOVERNMENT ❑ LEA EXEMPT ❑OTHER <br /> -f' ❑AGRICULTURE O COMMON CARRIEWBACK HAUL <br /> PICK UP LO <br /> O IMPORT FROM <br /> C1 DELIVERY ,h Cd WHOLE TIRE COUNT ❑WEIGHT IN POUNDS <br /> O EXPORT TO ❑VOLUME CUBIC YARDS O WEIGHT IN TONS <br /> Der t Certify that under penalty 61 perjury under the Iowa of the State of California[hat tM'rntorrnation provk/Cd above It;true and correct In addltlon,I <br /> ee.e o a am aware that falsification of this Information may result In oJvll penalties up to 525,000)W day,par violation of adthiniWiltiva penalties up to <br /> $5,000 per violation per day as described In Public Resources Code section 42962. <br /> CUSTOM�TaTXYh1T NAME CUSTOMER SIGNATURE DATE <br /> FSR No. 96524 <br />