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• i= , Waste Tire SAey & Inspection Repo* Inspection Report Number ■ <br /> State of <br /> CTWM Survey Form - Page 1 I - 4 $ Z <br /> CIWMH 181(New 04104) <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: ! D ?. 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP 0 CIWMB Q Complaint 0 Educational Visit o Other <br /> Business or Facility Name Inspected By Inspector <br /> A"y.cal Address 3�; q — ! 0 ( / ,.�,,, ,�"&�5, <br /> �.�f'"� <br /> Inspection Date ® / / •-,? —? J C <br /> Time In Time Out <br /> Business Rep )) pp Title / O AM O AM <br /> 0 PM I O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) i (Fill all that apply) <br /> ' ' Q 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 o Closed 0 Altered <br /> GPS Latitude + 0 Hauler 0 Indoor <br /> C Q Inactive 0Truck <br /> Longitude — + J o End-Use I Q Container <br /> 0 Planned o OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Relreader 0 Dismantler o Tire Derived Fuel <br /> f 0 Used Tire Dealer 0 Auto Body o Car Dealer o 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 _gNFgRg9 N f.STATUS <br /> - -- <br /> y; A` FiAt�LINQ AND.M NIFIST R G�UIRi;51N N`l'S _... ::...... T <br /> Q 0 PRC§42951 , o Ni; a Qf Vloiatlon 0 Extension <br /> 0 o PRC§42953. O; .11ancs Deadline <br /> PRC 42956• Brzt�shCarapedal&ts grri p <br /> 0 0 § <br /> 0 0 14 CCR§ 184, For All Your British Car Needs <br /> 14 CCR§ 184: David Nock <br /> O O <br /> 0 0 14 CCR§ 184! President&Service Manager (RBgU!(9d fQI NOV OI E?k <br /> o 0 14 CCR§184; (209)948-8767 --,-- <br /> 14 CCR§ 184t <br /> 0 0 2060 N.Wilson Way • Stockton,CA 95205 rs Il�lrlCIYVMI3 . nfarc+ tfnt <br /> 0 0 114 CCR§1841 Fax:(209)948-1030 Web Site:BritishCarSpecialists.com <br /> RESTORAT',ON'• SFRVIGE • REPAIRS PARTS <br /> (� 0 14 CCR§ 164t ierators # r ftp YtQllafls i <br /> 0 0 Other; <br /> Comments ] LJ l� c�m.'i,�r �•,� �../��F� `�.,1�^+e� -- �•�^— �'1 <br /> La v Ery o..—v <br /> +c> tn,;�v,( c6 Dv- - �,.— `tip Ccz�o r <br /> Inspection Form Include <br /> Comments Included: - � - <br /> Business ep's Signature Phone Number Ins ctor'sSignature Phone Number <br /> A + <br /> INSTRUCTIONS ON BACK GICf� ti ' I' L Ev i �� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:!-EA ® ■ <br />