Laserfiche WebLink
Waste Tire Sur y & Inspection Report `aspection Report Number <br /> �;---•-- State CIWMB <br /> f 81l New l i - 1088265 <br /> for�p Cgrated 1steManag) 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: I I I I 11 `- 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ / If Referral,choose referral type(Fill one) <br /> Identifier: / fi /` l/ ok <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name } Inspected By Inspector <br /> tI C r 1-�)Y�JI �� ��i�,{ ! ����� <br /> C- I � ( <br /> ,Physical Address j l <br /> Tc <br /> Jf-',r?� <br /> ;" Inspection DateL01 I <br /> State ZIP Co( . Time In Time Out <br /> Business Rep Titlle`"� (0AM Q AM <br /> Q PM V �% PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9.• 0 Active 0 Passenger i 0 Generator 0 Outdoor <br /> O ® Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - I. j I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AN MENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 <br /> 0 0 PRC§4295 JASON CURL Compliance Deadline <br /> Fixed Operations Manager P <br /> PRC§4295 <br /> 0 0 14 CCR§18 Date <br /> § M / m / m <br /> 14 CCR p 18i <br /> 0 Q ►(AAA e r [i X l'8 L L Phone(209)369-3573 Y:N C L Fax(209)340-5378 <br /> 0 0 14 CCR§18 Office(209)340-5407 (Required for NOV or EXT) <br /> 0 0 14 CCR§18 eAzmw <br /> - <br /> 0 0 14 CCR§18 camc PLUMMER PONTIAC ars 0 Referred/CIWMB Enforcement <br /> PONTIAC CADILLAC GMC BUICK <br /> 0 0 14 CCR§18 BUICK 1333 E KETTLEMAN LN - <br /> 0 0 14 CCR§18 LODI,CA 95240 merators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § / <br /> Comments 30 k L c (,CJ ,(i LZJ r— - f y'- �_(► �' _f;rc. <br /> _-r � '/I <br /> V-r i 1 -�i r r ✓f a �`:!r' V i �_""t j r� t ! �1 cf r�- r(t r c ( f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number In_�pector's Signature Phone Number <br /> X2131 <br /> -1 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ?C A Nt F, lr'F { 1 2 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />