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c�zr Waste Tire Su*y & Inspection Repore Inspection Report Number ■ <br /> ¢re <br /> Eoo state B California Il — 1141328 <br /> Cgrated Waste <br /> eManag) 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 O Inspection Type (Fill one) <br /> Site Suffix: I * Routine O Re-inspection O Referral O Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: 5cin J D ULlI j) Cox,nr O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Aufo <br /> Physical Address 3 9 I 0 <br /> �� Inspection Date <br /> O ` A ��� Time In Time Out <br /> Business Rep Title O AM O AM <br /> UVJm <br /> Oo'c M IJP, ,k�1 O 4 PM a S PM <br /> '—-----1 ` 1 u'-- --- --0 -fly - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Generator Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader a Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> 0O O PRC§425 A'�^ Notice Of Violation O Extension <br /> 0 0 PRC§425 N 1 Compliance Deadline <br /> O O PRC§425 M'A��Disma�t\ens_ <br /> O O 14 CCR§ s Date'm <br /> O O 14 CCR§ <br /> O O 14 CCR§ (Required for NOV or EXT) <br /> O O 14 CCR§ A200 X <br /> O O § 3757 W.Yosemite Ave <br /> 14 CCR aulers O Referred t CIWMB Enforcement <br /> O O 14 CCR§ es <br /> O O 14 CCR§ (209)858-421 8.4216 Generators <br /> O O Other: § <br /> www. ntecaparts.com In Compliance - No Violations <br /> Comments '^- n3_uys (10 of : <br /> � t <br /> Inspection Form Included: 0 -�Z��/ryni/�A�GG2 •,16� �Sp_Uz/6 � � _ 31�c, <br /> Comments Included: 0 y 7 J �01- q1 - a <br /> Business Rep's Signature Phone Number Inspec is Signature one Number <br /> INSTRUCTIONS ON BACK Corr 0 correct: X,�A IXIAIMIPILIEI 111213 62081 <br /> ■ White Copy:C Yellow Copy:Operator Pink Copy:LEA ® ■ <br />