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M. Ti�-�' Sum �'&'Inspedion Report. ewe lafi'R p�r�.�ut>nber_�'' <br /> stale cr Califorgia <br /> 194,ttdQ,.6d1, 4f fY�+�y� .y x <br /> Gellf4rn�alnU¢gralcd4Y�lollpnageo�enl6asrd S.••+++ f Y J Fo m �Ql a 1' � '- 1 ''0 A.3 _ 211 <br /> Part A-Survey. 13111—MOR BLACK[INK PEN <br /> v ' . <br /> tRIO • -. —,....�,• '-~ <br /> Inspectl4nType •(Fill one),, <br /> • Rpulire Re in ecliah Ffe' <br /> rtl Ofservaki�n <br /> • If Referral,choose referral type(Pill ohe) <br /> I.dentifler' f C)CHP •0 9MM6 Q Complain[. Rducatior'$l Vlslt f .01her <br /> Business or Facility Idama In9pecked Ry IiSspecior <br /> i7 et ti Inspection Date <br /> + --- -----•—_� S#�6 Z • 'Time In <br /> Time _, . <br /> s`B Sirrp§s Rei � : .; . Tittle I�k[v7 f I ANA <br /> FIM pli [ <br /> .. L.-_E] <br /> 0 <br /> Operational Status Bus*M Role <br /> K., (Fill one only) (Fill 2�I that apply) <br /> Active <br /> Generator <br /> Dr <br /> '• r, _ ,L _ <br /> Opt <br /> pGed 0. <br /> Hauler <br /> Q !rkacdve <br /> Lohgi6ude' Planned End-Use <br /> rx Haw, Tiro DoMer Auto Repair 1)Trucking'Fleek• Q Goveromed Q wreader (D Dismanfier 0 Tire.Darived FuO ' <br /> Used•Tir$Dealer '�Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber' <br /> 0 ServiCQ Station 0 Hauler C)AgricutturaShredder 0 Other L _.1 <br /> Dart B- Inspection of Waste Tire 0imaler, Generator,Hauler and End-Use Facility ENFER EIVlE�1T LATUS; <br /> t A r. C�AI�LIf� a' CNI .MA` IiFEST REQUII NIE 7S <br /> Y. <br /> {]'Nv#irm 4f:'Vlaiatloif '� C) 0 PRC§42951-Waste Tire Hauler Nag�'str0or<endTr ris rt a po of Tires tie ri ;N <br /> t' C ';Q PRG:§42953--Gontracta with Ragistsred Waste Tire Haulers: k Carnpuanue:0aaidlW _00 'PRC.§42956-,RegistrationfDecal in Vehicle <br /> " . 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§1a459:I{ (b){o}-Tire Program ID Numberfram C)WiAB• ' ;.'• : _ , ,. . <br /> 0 j4-CCR 18459.2.1 -Sub4rnittal of.Manit»t Farms and Tire Trip'Lags within 94 days rRe9T?uetl Y k l 7]' <br />' 0 14 CCR .18459.3 18459.3_Retention of Manifest.Fotms and Tire Trip Logs for 3 years '- ,•; <br /> 4 0 -14 CCR§1846%t=-N�artlfest Sys tom R2quirements-for Registered Wake TIce Hou leisl_: rRtfe[ 41 Fiori?arrmrA:" <br /> t 14 OCR§18461 ,-Mani€esk Systam Requirements far Wasto The EnddJse Facilities <br />!i r 71 D lers or Waste Tire Generators ' r ter ' ^:• r`' �'z <br /> 1d'CCR§10462-Manifest S stern Requirements for re as �• 7 .;' <br /> Y I` God I�a�?����.• �Y.ipji�t,'1�:,:' ; <br /> I. 0 .O otheT: - - - - •'�- ''.`•': N`�'•:S::r' .,L':•• ::;' '�'• <br /> •Comments � - - --- — ------- -J ._ <br /> -ff J•t •L!'f' 1�..{',,y� � -y^ .! , J•,-rr• �A•. .. '� •' <br /> - E <br /> i 62136'1 <br /> INSTRUCTIONS ON BACK r�o'rt��f'�.`;In�ofli+�i�: <br /> ■ Whte 60!y.,:ow l6 ' ' Yellow'Copy.Operatot 'PACGopy:LEA ■• <br />