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Waste Tire Sur y & Inspection Report Inspection Report Number <br /> ■ ni State of California <br /> CIWM8187(New04/04) Survey Form - Page 1 ��� - .1 -0 5 Q 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I} TPID- -v - Inspection Type (Fill one) <br /> Site Suffix: ! [�D] Q Routine Q Re-inspection Q Referral . Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: {r( AC" 11 y (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I 16gi r k kia,�?'rls; 0,' <br /> Physical Address - I J Pt <br /> Street <br /> t r Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> A ftrmyj _j 1 0 fJt'f.r Sm • m0PM [T-1 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 9 Active Passenger 0 Generator (Z) Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude m • � Q Hauler Q Indoor <br /> O Q Inactive Q Trucl <br /> Longitude Q Planned Q OTR Q End Use Q Container <br /> 4t I <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 /> j <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 Other pill, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q ' Q PRC§4' - -------_ - - - <br /> Q Q- PRC§4 Compliance Deadline <br /> PRC§4 <br /> Q Q 14 CCR �' nts Date m / [L] / IE <br /> Q Q 14 CCR <br /> Q Q 14 CCR Backr° ° Custom days (Required for NOV or EXT) <br /> Q O c• Yosemite • - <br /> ................_....--.----...--�-----......._......__ - <br /> --- . <br /> 14 CCR -Lathrop, - <br /> ` • 1 <br /> Q O 14 CCR Haulers Q Referred I CIWMB Enforcement <br /> Q O <br /> 14 CCR 209-830-1098 lities <br /> Q Q 14 CCR info@Backroe Generators Q In Compliance - No Violations j <br /> Q Q Other: <br /> Comments (r{�6�" /� s�� l:, r�%: � t` t��✓� ( ' T F L,��,Jtf vf�C1 � (`;a <br /> l/. <br /> ���?#J 'C%(r >��) /C/�_% t` ,` �jf d' #_ !�. c. 1 /fir=:;` .r .�r may!✓ 1 { L.� IL}rcr <br /> f <br /> Inspection Form Included Q. ' <br /> Comments Included. Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 0 �I [� �� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � �J ��� A �rlti P � � 11. c� � <br /> ■ White Copy:CIWMBy Yellow Copy:Operator_� Pink Copy:LEA ® ■ <br />