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Waste Tire S y & Inspection Re o"Inspection Report Number <br /> ® tf State of California <br /> CIWMB 181 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 Il - 1143595 <br /> Part A_Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- O I Inspection Type (Fill one) <br /> Site Suffix: l a Routine Q Re-inspection Q Referral Q Observation <br /> Localr� L If Referral,choose referral type(Fill one) <br /> Identifier: 15a J6_m ,ln Gun i_ O CHP QCIWMB � Com Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> t p Y Inspector <br /> , & s �i r r-s _ <br /> Physical dress 3 <br /> aaJ6 N - W►1son J <br /> Inspection Date <br /> o'��O� CA � 5205 <br /> Time In Time Out <br /> Business Rep Title 5 Q AM Q AM <br /> Nt�'� O � ® PM � � 5 0 PM <br /> O� AL u'1 ����� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �1 0 Active it Passenger ®Generator Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O Q Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) ----- <br /> Q New Tire Dealer 0 Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> 4D Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q PRC§42951 - -r„ - Q Notice Of Violation Q Extension <br /> 0 0 PRC§42953 Sal 37:4 <br /> Se Ha la f SJa�GhOhCompliance Deadline <br /> O Q PRC§42956- LB <br /> ii;G'- --: <br /> Q Q 14 CCR§1845 �'� Date <br /> Q Q 14 CCR§1845• %1 / m / m <br /> kta. <br /> Q 0 14 CCR§1845��a (Required for NOV or EXT) <br /> En 31 <br /> Q 0 14 CCR§1845 THRE-15-r <br /> Q Q 14 CCR§1846 - Great Prices 1 Q Referred/CIWMB Enforcement <br /> O O 14 CCR§1846 <br /> 14 CCR§1846Patches Pl.gs Tire Rotation <br /> FREE AIR PRESSURE CHECK rators <br /> On By ' id In Compliance - No Violations <br /> O O Other: § StocktON <br /> 11 <br /> , , sA � <br /> Comments rt �t�1.1 i <br /> N o vio�u�'it,�S-oS G�,L�.us _cl_F' �-Onccrn . <br /> Inspection Form Included: n <br /> Comments Included: Q — Q'1/-�V I f o 7,77 f5 J,Wct)ps <br /> - -_ Signature Phone Number ignatue 62081 _-- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: rG � E`} A P P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />