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Waste Tire *vey & I'nspection RepC9 'Inspection Report Number <br /> ® Tui State of California4O1 I 1 V V 6 jy� <br /> D A V <br /> CIWMB181(New 04104) Survey Forlm - Page <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey - <br /> Business Profile I Inspection Details <br /> T Inspection Type (Fill one) <br /> - Li c� _ l 0 Referral Observation <br /> Siteto � O Suffix: ` C ®Routine Re-inspection <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> Physic Address <br /> Inspection Date $ 3 <br /> Time In Time Out <br /> Business Rep Title \ �1 � AM � AM <br /> 0 PM 0 PM <br /> 6rsc ,� k_31_9 VV^11 Operational Status Tire Type Business Role Storage Type <br /> (Full one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE) - ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> PS Latitude 0 Hauler 0 Indoor <br /> G <br /> O 0 Inactive 0 Truck <br /> 0 End-Use 0 Container <br /> Longitude - 0 Planned 0 OTR <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 AND MANIFEST REQUIREMENTS —--__ _- 0 Notice Of Violation 0 Extension <br /> i 0 0 PRC " .--- -------- <br /> 10 0 PRC B�$�INGLE Compliance Deadline <br /> 0 0 PRC 2956 INDZJSTRIES, Inc. <br /> 0 0 14 C Z rements Date FF1 <br /> 0 0 14 C EAGLE,I-, " (Required for NOV or EXT) <br /> 0 0 14 C in 90 days <br /> tears <br /> D 0 14 C <br /> Herschel"Hersch"Beahm Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 C <br /> 0 0 14 C 4555 S. McKinley Ave., Stockton, CA 95206 Facilities .-------- <br /> 0 0 14 C Office: (209)932-2709 • Fax: (209)234-4367 Tire Generators In Compliance - No Violations <br /> herschb@burlingameindustries.com <br /> L 0 <br /> Othe --- ' - _ --- <br /> - - — - <br /> Comments <br /> � . <br /> o>n r 1�— l b� ck 0111 d�-�e-$ �t►'��y Y c S <br /> c��l � O <br /> C>v, S��e ��c.1`l U �� v�naw� �"� �`� ''1 ) ►10 �S` vL�3 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 I� I In o ' I re Phone Number <br /> Business Rep's Signature Phone Number <br /> �T= ------ - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ' ��il�' ��ll E 1 _j <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />