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® :nWaste Tire S Inspection Re - ort Number <br />State of CaliforniaCIWMB T 1088167 <br />California Integrated tWas81 te Management Board Survey Form ew 04104)- Page 1 i <br />Part A - Survev BLUE OR BLACK INK PEN <br />Site Suffix <br />Local <br />Identifier- GYl J U Q g U I n.�_.. ouurl-i"t9, <br />Business or Facility Name <br />NSF-�'iG11WA j <br />Physical Address <br />Street <br />g52�5 e <br />State ZIP Cade <br />Business Rep Title <br />C��ve C clr kock <br />__, r_.T_e1 rr 1 Ill e0 <br />GPS Latitude I <br />Longitude — <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />3iy <br />A <br />nspection Type (Fill one) <br />® Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />1 - <br />9K-�sk)nn Ltocus <br />Inspection Date O <br />/� <br />�ac) <br />A <br />Time InTime <br />OAM <br />Out <br />0 AM <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O PM <br />0 <br />O PM <br />Operational Status <br />Tire TypeBusiness <br />Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />,I (Fill all that apply) <br />(Fill all that apply) <br />® Active <br />0 Passenger <br />® Generator 0 Outdoor <br />0 Closed <br />0 Altered <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />0 <br />0 <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />0 Government 0 Retreader <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />U <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />00 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />0 Dismantler 0 Tire Derived Fuel <br />�.n-�c.rmc,ckal � <br />ENFORCEMENT STATUS <br />i <br />1 0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred I CIWMB Enforcement <br />IS In Compliance No Violations <br />Comments <br />dalQ <br />r��c���c� �'�t � ►1,�= t �_. c�c, rr, � r l � eca o�y ar � o_ u s � n- s i�c c. o >� t � civ r s � -._ <br />ni <br />—'��L►r ye.nc��_r� (�ia�.c1 -�or � �r� ��.�.rV►Ce- � C�a�_�'e �-tr-P. ��r�tuvg ,�., <br />to _Ix_ Mort CtCI _,I <br />`w^ti <br />Comments Included t ,; t� _ _ i <br />Business Rep's Signature Phone Number In actor's Signature Phone Number <br />- -- one <br />_ <br />62081 <br />INSTRUCTIONS ON BACK Correct:* incorrect: X 1' � �� 1 l.1 s L I I ° � <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />