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fq-j Waste Tire S y & Inspection Repo r# Inspection Report Number ■ <br /> C==-~ State of California <br /> CIWMB181(New04104) Survey Form - Page 1 1 - .3 0 0 8 0 2 2 <br /> California Integrated Waste Management Board <br /> ` Part A- Survey BLUE OR BLACK INK PEN <br /> 1 Business Profile Inspection Details <br />} TPID- O I Inspection Type (Fill one) 1 <br /> Site Suffix: ?j © Routine 0 Re inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP 0 CIWMB O Complaint Q Educational Visit 0 Other <br /> Business or Facility NameInspected By Inspector <br /> I / IiL�-lam <br /> PHysical Address <br /> Stree Inspection Date <br /> city- State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m ® PM m m 0 PM <br /> _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) tF o{ O D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �� t <br /> 0 Active (D Passenger C) Generator 5 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler Indoor <br /> D Q Inactive Truck <br /> Longitude - 0 Planned OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair 0 Trucking Fleet 0 Government O Retreader 0 Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture 0 Shredder O Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility h ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Q PRC§4 O Notice Of Violation O Extension <br /> Q O PRC§4 Compliance Deadline <br /> 0 ! O PRC§4 ` <br /> Q Q ,14 CCR I tb Ints Date <br /> Q 0 14 CCR <br /> 14 CCRI days (Required for NOV or EXT) <br /> Q Q 14 CCR <br /> O O 14 CCR ���. Haulers 0 Referred/CIWMB Enforcement <br /> 010 14 CCR I I ilities <br /> O I O '14 CCR I' I' , , e Generators O In Compliance - No Violations <br /> Comments ' /- t { .i <br /> nspection Form Included 0: r <br /> Business Rep's Si�nature Phone Number Ins"'c� tor's Signature r�? 'hone Number/ \, <br /> Comments Included. f - <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect p L 1 3 62081 <br /> 14V <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />