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Waste Tire Su ky & Inspection Report Inspection Report Number <br /> State of California <br /> If CIWMB 181(teManage) Survey Form - Page 1 1 8 - 10 7 9 19 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z -7 0 k 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5011 700LC(,A%0 C0uni j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A qua �OC Spa <br /> Physical Address I - f <br /> 1 Kr�s�t czh Lu GctS <br /> Inspection Date Q 3 � � O <br /> -t-1ante.C-k CA 9 S36� <br /> Time In Time Out <br /> Business Rep TitleCC O AM O AM <br /> -Ocp)t.t-i�ckur l vn O PM O PM <br /> Cat'tls �lar 1 er -dam` 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 /> f ' Q Active ! Passenger 40 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> O 40 inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 MCAnAacA 4v i 11 a PlLav - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> � �A PRC 42951 -Waste Tire Hauler Registration and <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Q 0 Notice Of Violation Q Extension <br /> nd 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ya.13na t nT C,+i on w a gas n ale rA 6 <br /> F c� no InxNOT maw nim _Vehicles A -this sIke . 6�kye'n►c1e- nncaIy }dnuc <br /> OGCuCs _- cA Z3l E. V:i9orn (TPID I4-0074 06g2er Cudis Fnarn1er, <br /> Inspection Form Included: Q (���� e (20a <br /> Comments Included: Q -- - _ 6 -3178 <br /> Business Rep's 'gnat re Phone Number I actor's Signature Phone Number <br /> • - x I -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: "/ XC M P L E 1 2 3 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA LA <br />