Laserfiche WebLink
ka <br /> Waste Tire St Ins ec i , . �S ection Re ort Number.Y p ton Repo p p State of California `t <br /> i' CIWMB 181(New nage Survey For>m - Page 1 - .Q 1 3 7 4 <br /> California Integrated Waste Management Board <br /> Part A SurveyBLUE OR BLACK INK PEN <br /> Business Profile ;Inspection Details <br /> TPID-. P �� r, r 1 _ Q Inspection Type (Fill one) <br /> Site Suffix: t!.' �<IJ /1 <br /> —,--�__ �� Routine Q Re-inspection Q Referral_ Q Observation <br /> Local �^ -) .S <br /> 1. If Referral,choose referral type(Fill'one) <br /> Identifier: Q CHP Q CIWMBQ.Complaint .,Q Educational Visit Other <br /> Business or Facility Name <br /> V Inspected By Inspector <br /> art PC,Q_,(hV �r �j�-✓ �,, <br /> �-1 '! o ` <br /> Physical Address _ <br /> r str .l- t 1 Inspection <br /> i pection Date <br /> r CA <br /> City State ZIP Code Time In Time Out <br /> Business Rep Titie <br /> }-{ Q [QN AM L/ �. S@ 0 AM <br /> PM <br /> BO <br /> I� r� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) U I I I I f� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Altered <br /> ® Closed Q: <br /> GPS Latitude ,� Q Hauler Q;Indoor <br /> Q Inactive 0 Truck <br /> Longitude - <br /> g 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 Q Auto Body Q Car Dealer Q Collection . Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (Z)\Other LR qil( c, `OyCr <br /> Pa <br /> V rt B Inspec'HAULtion <br /> AND MAIto Tire Dealer, Generator, Hauler and End-Use'Facility ENFORCEMENT STATUS <br /> A <br /> Q Q PRC§42951 -Waste Q Notice Of Violation Q xtension <br /> ARDCT <br /> Q Q PRC§42953-Contra ith PaH PARTS DEP <br /> Compliance Deadline <br /> 0_0 PRC§42956-Regist <br /> Q Q 14 CCR§18459 -Re� pacific <br /> Q Q 14 CCR§18459.1 (a) Date m m m <br /> Q Q 14 CCR§18459.2.1 - (Required for NOV o�EXT) <br /> Q Q 14 CCR§18459.3-R www•panpacificr% com - -- <br /> 14 CCR 18460.2-M 1-5 @ French Camp (209)234-2000 <br /> Q Q § 252 W.Yettner Road (209)234-0576 Fax Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Ma French Camp,CA 95231 fcparts@panpacificrv.com <br /> " --------- --- <br /> ---- ...---.. <br /> Q Q 14 CCR§18462-Ma -- <br /> Q Q Other: § �In Compliance - No Violations <br /> L�- <br /> Comments T V!t�Ll) t,;;ri I�._L�--f C ,t/! /�i.t � �(,t i ��t° 1 y r�UytS Ir•.. �( �(��!°�: /�I� C <br /> �:IJPS2 1.0t <br /> .i ,� I <br />— t�tis�'i-�'r1(�ct �ri�. / �✓ �firC' !_t f viC'°' < ti"�G1t'!<.�v:'f t �N fJ�aCQI f'tl`c^,� ��.t ��{� �� /e al�� .fl` - <br /> L< o , t� <br /> Inspection Form Included Q <br /> Comments Included: Q'Busines .R1p's Signature-`r Phone Number' ` Inspector's'Signature <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: X �P j.E�Xj,A[MjPj.LjEj1 12 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />