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EL3� <br />Waste Tire EAVey & Inspection Repi" Inspection Report Number ■ <br />State California <br />86aI 1 114 314 718 <br />CIWMB 781(e) Survey Form - Page 1 <br />California Integrated WasttManagement <br />Waste Management Board <br />Part A- Survey BLUE OR BLACK INK PEN <br />Business Profile I Inspection Details <br />TPID - r - Inspection Type (Fill one <br />Site Suffix: ` n <br />Routine Q Re inspection 41- 10 F2>3fe1?al Q Observation <br />Local - , If Referral, choose referral type (Fill one) <br />Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name v Inspected By Inspector <br />PI-) v1 U S <br />Physical Address - \ �Y/S�►1i bw� <br />Business Rep {Title <br />�cyVI <br />lJ U <br />Tire Count (Whole/PTE) <br />N <br />GPS Latitude <br />CEJ <br />Longitude - <br />Inspection Date <br />Time In tv Tim(e, Out <br />Q Planned I 0 OTR <br />Business Type (Fill all that apply) <br />0 AM <br />e� <br />I QZ <br />0 P M <br />operational Status <br />Tire Type <br />Fill one only) <br />(Fill all that apply) <br />Q Active <br />Q Passenger <br />0 Closed <br />Q Altered <br />Q Inactive <br />0 Truck <br />Q Planned I 0 OTR <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <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 0 Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A I <br />HAULING AND MANIFEST REQUIREMENTS <br />PRC § 4, <br />Q <br />Q <br />Q <br />Q <br />PRC § 4, Jorge Vega <br />Q <br />Q <br />PRC § 4< � Plant Manager <br />0 <br />0 <br />14 CCR <br />4343 S. McKinley Ave. its <br />0 <br />o <br />14 CCR ? <br />GROWELL Stockton, CA 95206 <br />Q <br />0 <br />14 CCR ? B R A N•D S P. 209 982 4936 <br />Q <br />0 <br />14 CCR F it TF. 877 548 9100 <br />F. 209 982 4937 <br />Q <br />0 <br />14 CCR F C. 209 321 5393 iaulers <br />Q <br />0 <br />14 CCR jvega@gro-well.com ities <br />www.gro-well.com <br />Q <br />0 <br />Contains Recycled Content <br />14 CCR F I Generators <br />I< <br />Q <br />Q <br />Other: § — <br />Comments <br />See - <br />Inspection Form Included: <br />I <br />Comments Included: ® -- --Z�� <br />B mess R s Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: <br />■ White Copy: CIWMB Yellow Copy: Operator <br />j 0 AM <br />L` ®PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator 0 Outdoor <br />Q Hauler <br />Q End -Use <br />Q Indoor <br />Q Container <br />Dismantler Q Tire Derived Fuel <br />'CIAC0 <br />Y,11 /-/,.&-rlG t /PZ <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date M/m/III <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />tl� <br />In pe fore Phone NumberEe <br />X A M j Ia 3 62081 <br />Pink Copy: LEA <br />