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g <br /> r, Waste Tire S & Ins ection_R.e oInspection ReporCwhlumber <br /> i� Y p p <br /> ii4� State of California � -- `` <br /> California Integrated CIWMB,Waste 81 eManagement Board SurVey Form` Page 1 .. . <br /> Part A- Survey BLUE O B- K:11 K'PE-N _ <br /> Business Profile Inspection Details <br /> TPID-. i t WM-t <br /> Inspection Type (Fill one) <br /> Site Suffix: ( { J I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J !'Z (,�C (,t t�1 �l i�� 1.' Q CHP Q CIWMB Q Complaint Q Ed'GdA iogal /isit Q Other <br /> Business or Facility Name l_) -- - -� <br /> �( Inspected By Inspector <br /> _ i ( <br /> Physical Address D /J� — L -t_ ---- _ <br /> J 1 ; <br /> Street or ^ � Inspection Date <br /> City State IP Code Time In Time Out <br /> Business Rep Title f (� /� @ AM f j Qt AM <br /> �I � i V � lJ O PM / t � � O PM <br /> Cl.�Q.f.P �. 0 1IO ��t�� �I -1to r'tr;��=k •----. ----- <br /> Operational Status Tire Type Business Role Storage Type <br /> �} I� (Fill.one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> (5Active Passenger Generator Outdoor <br /> FQ Closed O'Altered <br /> m • Q Hauler Q Indoor <br /> GPS Latitude Flo <br /> C Q Inactive (�)Truck <br /> Longitude - 1-1 <br /> Q Planned O: OTR O 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 (4) Dismantler Q Tire Derived Fuel- <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crurab Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other; I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS j <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q O PRC§429510 Notice Of Violation Q Extension <br /> �1 O►nAS' <br /> O Q PRC§42953 owntA Compliance Deadline <br /> QQ PRC§42956 <br /> O O 14 CCR§184 Date M <br /> O O 44t & a tla (Required for NOV or EXT) <br /> 14 CCR§`18 <br /> O O SCOUTS WE R <br /> O` O 14 CCR§184 SPECIALIZING IN INTERNATIONAL - — <br /> Since 1947 <br /> Q O 14 CCR§18 f� S OUTS•TRUCKS• AMERICAN 8 FOREIGN CARS rs Q Referred!CIWMB Enforcement <br />^ O O 14.CCR§184 Marft-�a•Lathrop Stockton <br /> (209)858-4216 (209)982-5214 —- - ---- — --------.. - <br /> . 0 O 14 CCR§18 ! 3737 W.Yosemite Ave. Lathrop,CA 95330 ierators (4) In Compliance - No Violations <br /> Q Q Other: !— <br /> Comments (��t1 .t t(1`;y_ �s L:.I�, �.t 1 ) i✓�:' Cf` '-e .l' t l v t - <br /> 05E4 VJ -/t r-s, f h VV&J,45 ay A Yirlle or ,� ;�,,' I;re S <br /> ria1� I(ff Civt lFr od Mfr I-��� c��r c 0fv , I�.k 'rtid �Un 111 ,4 E S� oUnk - <br /> a!���. � f�1'rlC��1 �� � E .l� � ���u/ ✓ /t�� rt e:( f':; t'r�Sslcl � r ;r-crr�i <br /> Inspection Form Included: O',' <br /> Comments Included O? - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Krrect: Number <br /> r�;, 62081 <br /> INSTRUCTIONS ON BACK0 Incorrect: w E[?� ,AIM P � E 1. <br /> s■ � White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA - <br />