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rCT_Q4-2007 THii 10: 5-3 AM CO aU1TkAIIER1Sa1ES11ICF-.,F 1GJ1Q F :?05 313000 P. 006 <br /> a y WILSON "Y TIRE CO ,,;INC. # FLEET SERYtICE RECORD <br /> U.S..TIRE SALES TPtD 1000837. 102891 <br /> smr Witten way Tree U4tsort ftw me Recapa^ff see xmsen wW r" .?f us raw OPW �z,M76r Sufea pastes Tno wire <br /> mix Wa en tyey ,SM MWrkct SL 7S7t :�Iwklr <br /> K 1117 W.Mleventl+SL 7400 yesem"6Md ,9161 h lig Ave, W9diiar kAW 6hd <br /> SteaRab C41.915705 SmodRan►a Ss"s �992M !racy,as.Own m"000,a&$"" teeyward,ea."S" tllWMMWM$%"OSM <br /> 1145 4 sorsa 1lS911a Yicti f ads.820-44107 209,S".Wtl afe ass-1:r� s+ <br /> CUSTOMER �? �r P.O_# DATE ' <br /> PHONE VEHICLE# / <br /> LIC <br /> LOCATION OF SERVICE .1 STATE . 9P CODE <br /> Ze <br /> CUSTOMER TPID — DECAL*' <br /> I certity that under penalty of perjury under the laws of the State of Csitfomla that ttte itftrmatiom provided above is true and cefnacL In a"don,1 am aware that fa{sirto5on of. <br /> this inf9r ation may result in suspension,revocation,or denlef of renewal of the Waste Tiro Mauler R"Ieftdon pursuant to Public•Rescure"C400*tW*n 429M and may <br /> result in eivil penalties up to 825,000 per day;per violation or_sdministretwe penalties up to 45,000 per violation per-day ss described in Public Resources Code.asctlon 429112. <br /> DRIVER NAME DRIVER SIGNATURE DATE <br /> e cJ� X <br /> MAKE•,. TRUCK rPAILER#_; ! LICENSE STATE ODOMETER/HUB <br /> SPECIAL INSTRUCTfON$' . . _:" E pN <br /> QTIri' ::,• 'QESEAIPTfON 01P WotfZ`69tilR T D,^ OTY_': D lP77GN Ge?INQRK COH7P!ETELf ,•;;.. OTY.'? .,,. DESCR 1 FIbN-OF.iRlQR1G'COMPtETEO <br /> SERVICE.CALL MOUNT!OISMOUNT(Sj ON VEHICLIiJ ', SS. VE STEM(Sj: , <br /> FLEET INSPECTION MOUNT I DISMOUNTS)LOOSE M(S <br /> AIR SERVICE LOOSE MOUNT($) \..;'�` VALVE 1rTEM.Raa8U1Lt4{ <br /> FLAT REPAIR(S) ',I1�. ' LOOSE DISMOUNT($) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL($} r'r'' 'TIRE(S)BALANCED '. METAL VALVE CAP(S) <br /> WHEEL SWITCH($) RECONDITIONEDWHEEL(S) O AJNG(S) - <br /> QTY: . SIZE "MFG :; .. DESC iPTtO �, . FtN19M MILES: —._.. <br /> 7-4 <br /> �� t•1.. �� ^ TOTAL MrLES: <br /> c.;.. �, �i fi rj !C �/ '�. �,: I STARTTIME: �G AM�►w~%. <br /> — ON SITE 71ME: AM PM <br /> oVTTIME Au PM <br /> FINISH TIME J AM�Qr1�' <br /> LOAD AMOUNT ". `HA R. EMPTf N IF APPLI ASCE <br /> ` O GOVERNM : 'p LEA EXEMPT OL OTHER <br /> —1 -- ❑AGRICUL E . ] COMMON CARRIER/BACK HAUL:. <br /> PICK UP `. `. r LOAD':TYPE _ <br /> ❑ DELIVERYa:'oft �� � HBLE TIRE•:000NT - •E3 WE)GHT IN•POUNDS' <br /> t <br /> EXPORT.T0 i` / t�.c'� /./'2r DVOL•UME CUSIC YARDS C�!�►EIG�+'t iN-TONS <br /> 1 cert7fy that under penalty of perjury under thoalaws of tlw Stats of California that the iriformetion provided above is true and correct In addition.1 <br /> e,-Dajo'n am awarethat falsification of this InforMatlon may result In dvll penalties up to 525,000 per day,per vlelatim or admInletradve penalties up to <br /> ea SS,OOO Istlon per day as described in Public Retouroai Code Seaton 42962. , <br /> e <br /> CUSTOMER PRINT NAME CUSTOMER SIGNATURE DATE <br /> FSR N0.102891 <br />