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Waste Tire Si & Inspection Repospection Report Number ■ <br /> ■ ',--���°�� State of California 11 - 1088003 <br /> Sate of 81 fornix /04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> - <br /> Part A- Survey - --- <br /> Inspection Details <br /> Bus'iness',I�rofil��� __ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix =L�7( q ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: Jr,n 7Q� cif 1 1 Gvt(�� <br /> q y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> a Na..r C cel--._�«ns_c)or _ K:C�c� era �o L-2 _ 1O1sical Address , 0 ��Y P L u c CAS. .� <br /> 2 o M un�r�r Aqz -- <br /> Street _. �_.._ <br /> Inspection Date <br /> CA <br /> City C State C1P Code Time In Time Out <br /> } <br /> de O AM O AM <br /> —_... - - —._ _. <br /> Business Rep Title <br /> O� SCGO PM ._-- PM <br /> _ Operational Status Tire, <br /> e,TYp BuRole Type <br /> ( ony) (F that apply) ( ll all that apply) all that apply) <br /> y) <br /> le Active Q Passenger (3 Generator Q Outdoor <br /> _ _ O <br /> GPS Latitude . � Q Closed Q Altered Q Q <br /> Hauler Indoor <br /> _ Q Inactive Q,,Truck <br /> Longitude m , I I 1 1 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 Q Tire Derived Fuel <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 s e-rn1 TY-CAA yr E r V 1CQ/(� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days i <br /> O O <br /> 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 /> 18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 CCR§ - em <br /> � In Compliance - No Violations <br /> QQ i Other § - .. _ _----..-- - ---- ------ --- <br /> Comments <br /> .e..d -�ih�s LjccfiE 011 KGs <br /> moo ed Fac� 1Is �� ery 1 ow vo]t_1>rc G e..ne-1 r w_cts're <br /> wase tyre - © —. Go W1on ltdo,, Ttre <br /> ( J _ <br /> Inspection Farm Included: Q, / <br /> Comments Incuded: Q Business Rep's Signature F Phone Nuinb �° � ° F ° t �* Phone <br /> Number <br /> _ 62081 I <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X v �, : LA I-,k ` <br /> ■ _ I _nko._3._ I ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy;LEA <br />