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=_ Waste Tire SSW & Inspection Repor' Spection Report Number <br /> LE <br /> 112. <br /> LaState of California <br /> CIWMB 181(New 04104) I 1 - 1088338 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` C r) Q / -_ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: {� ©C�' �('J�,�` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address - 0 <br /> O E - — <br /> /'�n G � C+ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I, _„ O PM O PM <br /> L0 l -i��,-(✓1 � �S�tl n�Cx � /�V InLL`LJ�I'9 - - - - <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 apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ® Inactive Q Truck <br /> Longitude - 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 0 Tire Derived Fuel <br /> Q Used Tire Dealer n A.,'^D-A• Crumb Rubber <br /> vi <br /> Q Service Statior .■�■� �'n/C � Other LLl I vQ <br /> - <br /> Part - uRAILROAD <br /> n rRr B - Inspec -Use Facility ENFORCEMENT STATUS <br /> 0 Q PRC§I PATRICK L. BURRIS <br /> Q Notice Of Violation Q Extension <br /> 0 0 PRC§ //q fJ� Compliance Deadline <br /> 0 0 PRC§4 (� /'C < <br /> Q 0 14 CCR EAST ROTC ROAD ?ntS Date m <br /> O 0 14 CCR <br /> FRENCH CAMP,CA 95231 <br /> MANAGER INTERMODAL PH:12091 942-5279 <br /> 0 0 14 CCR OPERATIONS FAX:12091 942-5395 (Required for NOV or EXT) <br /> 0 0 - _ <br /> 14 CCR y --,.,o.o-rmelention of t;omprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> - ----------------- ------ --- - - <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 16 0 Other: <br /> Comments § �G,, <br /> l r ze ►d 2V1( oY'Jam' Orl c�1 �>� ��t° ✓!Le �r�t�._ Ay' <br /> rai 1 W aect CU-5 f-b 1`3n&13-7 , 14 005 , ally 13;� $(271 <br /> A1 DO a -c cq s ,,D eh.&ra;� �isfie. -ire . TAar-1 vat e TP)D#- <br /> 0 10/ <br /> Inspection Form Included: Q 19��y <br /> Comments Included: `� <br /> e e Sign ture Phone Number Inspector' -signature - Phone Number <br /> INSTRUCTIONS ON BACK ENS AIS p111 -713 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />