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t <br /> Waste Tire Sui „ey & Inspection Report Inspection Report Number ■ <br /> F57'+ State B California Il 1143570 <br /> ov a Cgrate 181(New nage) Survey Form - Page 1 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q I Inspection Type (Fill one) <br /> Site Suffix: p� 1 R 5 4 � Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locala <br /> If Referral,choose referral type(Fill one) <br /> Identifier: U n o� 1� Cm 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> z ucwcl mAn - I�C_rI' 1c IN_ 31 - I 0 1 <br /> Physical Address J ko Esco�o <br /> P_6. 6ox M1 61n k)f aaU lslkndk IIVVV <br /> Inspection Date <br /> 56(.�t 0 CA 9S204 l <br /> Time In Time Out <br /> Business Rep Title �f 5AM r AM <br /> r� 1 0 1 0 PM ' I 5 O PM <br /> H �Ln�leac� d cr. D�rec,�or Operational Status Tire Type Business Role Storage Type <br /> ^ <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d d <br /> 9 Active 0 Passenger * Generator 40 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler ®Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ------.--- <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - ----- _... <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A <br /> 0 In Compliance - No Violations <br /> 0 Other: § _ ],l <br /> Comments 'SIR BOG (lU(1lL� t�, 1 n*cRon t6nr (111 5 d cA ( G <br /> N O V Z O U, DA S 6 t (A(eu,5 O7 (,Ur U �1 - -- - - __ <br /> Inspection Form Included: 0 f <br /> d. �nnsp _ \_M✓ <br /> Comments Included: 0 —�U.1 e- ---- - -- ---- _ �' Sigp <br /> Business Rep's Signature Phone Number ture _ Phone Number <br /> INSTRUCTIONS ON BACK �Correct:l0 Incorrect: %tel ! E XC A 11213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy L © ■ <br />