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ve" <br /> ,= Waste Tire Survey &' Inspection Report os <br /> pection Report Number <br /> AA State of California - <br /> AA� CIWMB 181(New Survey Form - Page 1 .2 - 1 0 .1 3 4 2 .1 <br /> California Integrated Wastt Management <br /> 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 <br /> Site Suffix: Imo( 11 f �' <br /> Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t �� t�<r (,4,' i <br /> O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name VInspected B <br /> P y Inspector <br /> Physical Address v <br /> *Mew ) _ <br /> Uel�i� 1/4 t.{ 1 e A t/'-( I --- - - <br /> Street <br /> �/ Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> AM ( ) Q AM <br /> O <br /> ©'PM (D�/ PM <br /> k( <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I I I I I y I / (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> O Active, 0 Passenger O Generator Outdoor <br /> GPS Latitude O @ Closed O Altered f <br /> O Hauler r"jf 0 Indoor � f <br /> 0 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 O 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 Q Shredder Other I f V f 1 / <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC_E_MEN_ T STATUS <br /> LVJ A ,HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§ O Notice Of Violation O Extension <br /> O O -PRC§ MOTORHOMES-TRAILERS PARTS& Compliance Deadline <br /> O O PRC§ 5th WHEELS-CAMPERS SERVICE I <br /> O O 14 CCI ents Date <br /> O O 14 CC <br /> O O 14 CC Manteca Trailer & Camper, Inc. days (Required for NOV orEXT) <br /> O O 14 CCII 2060 E. YOSEMITE AVE. s ---- ------ - ---_-- .-. <br /> MANTECA, CA 95336 <br /> O O 14 CCR - Haulers O Referred/CIWMB Enforcement <br /> O O 14 CC f ilities <br /> O O 14 CCR Phone(209)239-1267•Fax(209)249-2640 re Generators <br /> Q O Other: <br /> www.mantecatrailer.com O In Compliance - No Violations <br /> Comments r <br /> �:s r. ✓(J �.. . f( f i ? r`1 1 //t; i"�4. � �� J�.l F i i -) j <br /> J <br /> A f 0 ~`m/;- �l'. (sif {.�rLitcl,( <br /> f <br /> (51 r:r�( ,, ail !.r _ � t:��l,,{� f � �'fL:l.a it :4i itr��' i (;t' �t�✓3'I/( ( v<)I �G� � ( � �. <br /> G rayl , .� fr�( 1� C/f ►l'Q� �1 ��P J�, chto V to _ o+r <br /> Inspection Form Included 0 � '._- �_ -- .- _ •I__�_ � t' " /t 9 <br /> !. `, t t f'L i ( ' (sem. , ! ,I- <br /> Comments Included Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: W .i�NM L 1 62081 <br /> X ' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />