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Waste Tire SOMrVey <br /> y & Inspection Repo Inspection Report Number <br /> State of California <br /> CIWMB 181(New04104) Form - Pag(''�e 1 I1 - 1088338 <br /> California Integrated Waste Management Board �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 0 / a / ® Routine Q Re-inspection Q Referral 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 Inspected By Inspector <br /> o <br /> Physical Address <br /> 1000 E <br /> Y n c� C+ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Zi UL <br /> ✓ -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) S. (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 r'1 A,.'^0-ACrumb Rubber <br /> Q Service Statior UNMIN MC'RC Other Rat y � <br /> Part B - Inspec ORNLRW -Use Facility ENFORCEMENT STATUS <br /> jQ Notice Of Violation Q Extension <br /> V A ' HAULk l' <br /> Q Q PRC§ PATRICK L. BURRIS <br /> Q Q PRC§z //qf��j' Compliance Deadline <br /> Q Q PRC§4 <br /> Q Q 14 CCR 1000 EAST ROTH ROAD Pnts Date <br /> m m / m z <br /> Q Q 14 CCR FRENCH CAMP,CA 95231 <br /> MANAGER INTERMODAL PH:(209)942-52791 <br /> Q Q 14 CCR OPERATIONS FAX:(209)942-5395 Required for NOV or EXT �I <br /> Q O -- - <br /> 14 CCR Retenuon or t;omprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § _. - <br /> Comments '-rI C cf- t, Ar <br /> r-a -1 t Ctr'C�5 fb +'V1Qv� � C 1�1u�5; j 3�(¢1 � l � 0Q5 � � QnC� <br /> �dr1ID0 ! Pao.-i.Sc cAoes 4►at_ +" -WE��fie -�zr s p T-4aGfiva-fe TPO—* <br /> Inspection Form Included: Q <br /> Comments Included: <br /> e e Sign ture Phone Number Inspector' ignature Phone Number <br /> INSTRUCTIONS ON BACK tr ;�3. FENAIMIPILIE1 IIIZ13 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />