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W <br /> ® Waste Tire Sky & Inspection Repol Inspection Report Number ■ <br /> ''tl•Z`. State of California <br /> ®� SurveyForm - Page 1 Il - 1088247 <br /> p CIWMB#81(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A'. Surve BLUE OR BLACK INK PEN <br /> — - - - <br /> Business Profile` Inspection Details <br /> i- _- <br /> TPID- j Inspection Type (Fill one) <br /> Site Suffix: � 3 3 � �� Z� G� 1 V I <br /> - Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: - �rn To (-A 1 Yl Cn is <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p Y Inspector <br /> I _es c,h�ctk� Tire Cey)Aer,_ jPhysical Address � 111 <br /> 0 <br /> LI <br /> L_ 19) <br /> Street — [951 2_.._q.__. _G.1 <br /> Inspection Date <br /> t n CA 95�Z0 <br /> Cit �__ Sfafe 7iP Cocle,.f Time In Time Out <br /> Business Rep Title0 PM PM <br /> O AM <br /> Ton,_ C�r,cadw k M�v�c, __�] <br /> Operational Status Business Role <br /> O (: (Fill one only) "'' (Fill all that apply) <br /> ® Active ® Generator <br /> Latitude _ O Q Closed <br /> CIPS �_�• t ® Hauler <br /> O Q Inactive <br /> Longitude - Q Planned Q End-Use <br /> - <br /> Business Typetll ' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <br /> Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> V � A HAULING AND MANIFEST REQUIREMENTS I Q Notice Of Violation Q Extension <br /> Q Q § 9� p <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years — -- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q §§ YRequirements - --- — <br /> 14 CCR 18462-Manifest System for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Other: <br /> Comments C� (U� <br /> O tr t Y o( -) �Q -} J <br /> Pro ,, 3C} .,la -'t ire: s ofed on- _��e, Fa��1 - oris t;.sasle_ <br /> � �Y2S 1r a_ con cg\n2C Con_�nIrQr <br /> V,ok'A t ri 0, <br /> Inspection Form Included: Q; ' ' r <br /> Comments Included:Q'Buss Re �Signature Phone�Number �Instiect is Signature ,f Phone Number <br /> - <br /> .. _ ser. <br /> INSTRUCTIONS ON BACK Correct:® incorrect: � i ,,I,� ( 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />