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rrrr.y,.a rr__..___._�_vr.-...r•.+......... �T..___ ...�....,_____-_-r___.-.—.w .___._.__,.._. �__s Gam.__...:.t �_._____-_..______________.._._r. .v __.____._V,._r_:.___.___,_err._.. +�•____,___-___-.__, <br /> Report Number <br /> C6Waste TPr'�Su ey & InspectionMort"nspectio'n � <br /> MEState of California T 1 - 1140975 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A_=Survey _ �— BLUE OR BLACK_ INK PEN <br /> Business ProfileInspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 5 7 l Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V %J * �. W111� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> y g(,�e�-5 t1 rho, 5 G1 5 - l (� l ( ►amb.)l� <br /> Ph sical Address <br /> 1Lvi co <br /> Inspection Date I <br /> Time In Time Out <br /> Business Rep Title .q' O AM O AM <br /> &k p2 OZ © ® PM ®PM <br /> L.i � 2► ?.�eti EAvhmmCAJZ &V-ijkiffe, ----- — <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4@ Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <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 ��� c.,tt�f ►iwi <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q-- HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42E <br /> Q Q PRC§4Z Compliance Deadline <br /> Q Q PRC§42S Regi; <br /> Q Q 14 CCR <br /> § s Date M / m / m <br /> Q Q 14 CCR§ Lisa Mendoza <br /> Q Q Environmental Supervisor (Required for NOV or EXT) <br /> 14 CCR§ <br /> Q Q 14 CCR§ I 14700 W.Schutte Rd. <br /> Tracy,CA 95377 <br /> Q Q 14 CCR§ +1 209 836 8269 tel )ulers Q Referred/CIWMB Enforcement <br /> 14 CCR§ +1 209 836 0707 fax fes _ <br /> Q Q lisa.mendoza@o-i.com -- <br /> Q Q 14 CCR§ www.o-i.com Generators ® In Compliance - No Violations <br /> 10 , 0 Other: § <br /> Comments <br /> Inspection Form Included: Q _ Q <br /> Comments Included: pusiness --- - 4-- <br /> 62081� ZZ'3 Rep's Signature Phone Number In or's nure phone Number <br /> _ --,/ I- <br /> INSTRUCTIONS ON BACK �,!"Correct:* Incorrect: t Y� .A'II 11 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :l- <br /> ® ■ <br /> I <br />