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«_. Waste Tire Suy & Inspection Repo- , e Inspection Repot NumberState ■ <br /> CIWMB f81CaliforniaNewSurvey Form - Page 1 I S - 7 '2 8 Z <br /> CIWMB 181(New.04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c [�5E_ Inspection Type (Fill one) <br /> Site Suffix: O 9 C-) () Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C1rl1- t, t.( rl t,Pa. 1 O CHP 0 CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility Name 1 Inspected B <br /> P Y Inspector <br /> l A-r 1 1 'r r, �,_. -�c ,r , , t r_� C �_ni C -i <br /> Physical Address - ' O I <br /> l 'LIS 127 __,C h 1 r i <br /> Street <br /> Inspection Date <br /> I T(rtco C Acar �7 ll <br /> City .J State ZIP Code Time In Time Out <br /> Business Rep Title m ' m 0 AM 0 AM <br /> 0 PM ' m 0 PM <br /> % k_1�r.G A�Vf: y <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole PTE <br /> EEI:(Jo <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Lj'= Q Active 0 Passenger 01 Generator 0 Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude m , i Q Hauler Q Indoor \ <br /> O t� Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair ® Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel \ <br /> O Used Tire Dealer O Auto Body 0 Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility, ENFORCEMENTSTATUS <br /> FV A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§ 1 0 Notice Of Violation O Extension <br /> 0 - 0 PRC§4 {' <br /> 0 PRC§4 R ,leStro <br /> � <br /> Compliance Deadline <br /> t C <br /> 14 CCR C <br /> Q � Q 114 CCR lstributlon nts Date / m / <br /> �I Paul Van de Roovaart <br /> Q Q 14 CCR Centers in-c. Executive Vice President (Required for NOV or EXT) <br /> O . O 14 CCR <br /> O O 14 CCR Haulers Q Referred I CIWMB Enforcement <br /> Q 14 CCR Phone 209-839-0553 • Fax 209-830-0687 lities <br /> 14 CCR 25127 Schulte Road • Tracy, California 95377 <br /> e Generators <br /> paul@via-palestro.com • www.via-palestro.com In Compliance <br /> 1010 <br /> I O - No Violations <br /> Other: <br /> i . <br /> Comments t ` <br /> -- -j'-p_A L 11 �tI"t•- <br /> r�} L_� Fas a1L��-- c_: .- r� � __r, sNL,,C c <br /> yJ � <br /> I r,\ �-�i-ti VA-L+ _F'_I C <br /> — i <br /> Al <br /> Inspection Form Included: 0 <br /> Comments Included: i _ -. . <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,���` 62081 <br /> ,gip Ihlt p <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />