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M Waste Tire SuOy & Inspection Reporm, Inspection Report Number <br /> NW <br /> State B California I 1 - 1140623 <br /> CIWMB 161(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey ____ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 02 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> JAM <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> MU _ <br /> Physical Address / $ / E 0 <br /> 02 SD t✓V1 �S t� !/�/� <br /> Inspection Date / O b / 0 <br /> fvc.�fan �S�o� f <br /> Time In Time Out <br /> Business Rep Title / ® AM ) S AM <br /> /"za� , O PM / / S O PM�r Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f / ® Active ® Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) _ v <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A . HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> Q Q PRCi <br /> Q Q PRC! Compliance Deadline <br /> Q Q PRC! <br /> Q Q 14 CC rents Date m / m / m <br /> Q Q 14 CC We Provide Freedom- <br /> Q Q 14 CC HAROLD ALLAN (Required for NOV orEXT) <br /> Fleet Maintenance Manager _ <br /> Q Q 14 CC Division#9,#31&#98 <br /> Q Q 14 CC 1250 S.Wilson Way I Ste.A-1 I Stockton,CA 95205 to Haulers Q Referred l CIWMB Enforcement <br /> Q Q 14 CC P 209.941.1639 1 F 209.547.7880 ilcilities _ <br /> Q Q 14 CC C 209.915.3980 Tire Generators <br /> hallan@mvtransit.com '0 in Compliance - No Violations <br /> Q 1 Q 1Other. <br /> Comments <br /> 1�.ru�—;h�r,��cr•.� av►- �,�r t�ic,�v cum/ � <br /> OE <br /> ---mak --- <br /> Inspection Form. Included: Q <br /> Comments Included: <br /> Busine e s ignature. Phone Numb be_�� Inspector's Signa e. Ph.one.Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7h A 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L ® ■ <br />