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08024040131 <br /> =o, Waste Tire Sulfty & Inspection Report•Inspection Report Number ■ <br /> �r alateolcallf <br /> CnvMalal to 09/04) Survey Form - Page 1 1 1 5 - 10 7 9 4 18 <br /> California Integrotad Waste Management aeard <br /> Part A-Surve t BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 O I r O 1 Inspection Type (Fill one) <br /> Site Su.. I S ®Routine Q Re-inspection Q Referral Q Observation. <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: . 1AI4 COLAQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L-Frier,►dl . Cheyrole 'F5191 L <br /> Physical <br /> gMiddres <br /> StreetC ^ Inspection Date <br /> ��l <br /> City State ZIP Code ED <br /> Time In TimeO <br /> ut <br /> Business Rep Title m O PM m O M <br /> P4ft . <br /> " - --- Operational Status Tire Type Business Role. Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appy) <br /> Active Q Passenger Q Generator Q.Outdoor <br /> Latitude I I I D 0 Closed Q Altered <br /> I <br /> GPS LQ Inactive Q Truck—�-1•�_ I ,-�� - Q Hauler Q Indoor. <br /> 1 <br /> Longitude - I I I I I I 10 <br /> Q Planned Q OTR C)End-Use Q Container <br /> Business Type (Fill all that appy)_ 1111 _ �/A- )J/R- Al <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 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part E =acilityENFORCEMENT STATUS <br /> - - <br /> A IND. <br /> Q C§4 , Q Noti Of iolation Q Extension <br /> Q C - - Compliance Deadline <br /> O C <br /> Q C <br /> ESC��LOry Date m / m / m <br /> Q C 2996 S.McHenry (Required for NOV or EX7J <br /> Q C <br /> Escalon, CA 95320 <br /> Q C Tony Muto Bus:(209)838-7351 5 Referred!C-IWMB Enforcement <br /> Q C Parts Manager Fax:(209)838-2748 <br /> Q C MIIIIIEF erators ®In pliance - No Violations <br /> Q 1 C _ <br /> Comments <br /> iMc,_1_vl_r <br /> inspection Fonn Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature._: . rPhone Number.--: spect.es Signature Phone Number: <br /> . I� 62081 <br /> INSTRUCTIONS ON BACK Corr et: Incorrect: � A Ah P E 1 Z 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> �I <br />