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W. Waste Tire S & Ins inspection Re Or Inspection Report Number ■ <br /> State of California + p I �1 <br /> Survey Form - Page 1 1 8 - 1 0 1 3 2 2 2 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board ! '. <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 11t^ali4 c �I� �'^ r k <br /> FIN <br /> TPID- �.., Inspection Type (Fill one) <br /> Site Su <br /> ffix: 1 ( - <br /> f� / <br /> -- �Routine QRe-inspection QReferral <br /> Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: -. <br /> ( S, I /. h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name { ( Inspected B <br /> p y Inspector <br /> Physical Address <br /> p f f t_ S f N1 f JC <br /> Street <br /> ( �f Inspection Date <br /> _ rA <br /> J L <br /> City State Zip Code I Time In Time Out <br /> Business Rep Title 11 Q AM I F 0 AM <br /> 0 PM 0 PM <br /> L, 1 ( t.��.,j_� I�_'.�___ s� -���✓1.--i I� ��; t I..,�b i - - — s;a-ya*w�^�`7'w�a� w r a 'TT i . <br /> Operational Status,5,fi Business RoleI <br /> (Fill one only) (Fill all that apply) <br /> „ ., Q Active rwt +Pe'"3`rrl' " , Q Generator ';GQ1'MQI (IQEfif[� 4rIuY,. <br /> ��p„'4u"r� r�/tt��ai�Fn✓��ti� �"`"����>�'� +�rr ���Ir7 <br /> GPS <br /> Latitude (, Closed �tk�k �� � <br /> Q Hauler <br /> O ftp r <br /> Inactive <br /> ^: <br /> LongitudeEnd Us <br /> Q <br /> � r � �t��r, t r'� " � r� r{��' p„:�,r ;�X”✓qtr, m; <br /> kr <br /> ,.; �`_.".`".'..���'!�.�..^y�.nS�e,.�.✓.�_...� ?.,____:4..,.;t"fi,,.�rk��w.a_..,w�J+��1�n.,�r�x `,��w�t r����.�..,wr��,�rp�r1.� ��.rr� "ray'.i�A r�,� �b.�a� r�ti5�wv.��2���t,.�r i <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V <br /> - — _ <br /> h <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42 - Q Notice Of Violation Q Extension <br /> Q Q PRC§42 �� <br /> Compliance Deadline <br /> Q Q PRC§421 RepFIA <br /> •�� <br /> Q Q 14 CCR F <br /> its Date m m m <br /> QQ 14 CCR ��� I <br /> = r <br /> Q Q 14 CCR days - (Required for NOV or EXT) <br /> Q Q 14 CCR -- _ _ <br /> Q Q 14 CCR °°° iaulers Q Referred/CIWMB Enforcement <br /> Escalon ° <br /> Q O 14 CCR <br /> phone. • : o• ities — -Hi I - — <br /> Q Q 14 CCR Todd •General Manager • Generators <br /> Q Q ( In Compliance - No Violations <br /> Other: § <br /> Comments <br /> 7� 1I <br /> L j <br /> r t > <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />