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0823484027S <br /> Waste Tire Survey & Inspection ReportInspection Report Number ■ <br /> State ofCal'dornla Survey Form - Page 1 I1 .- 1088.130 <br /> CIWMB 181(New 04104) �/ <br /> califomia Integrated Waste Management Board J <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' jg - O I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local y If Referral,choose referral type(Fill one) <br /> Identifier: ( To,%qu ri coun{'y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �U S_.__Pos�-a1 service_(_v_nr) 1 3 q - 0=1 <br /> Physical Address �K_r_is4lan Luegs_J <br /> Street <br /> �313�_Acch A+r pock Rd. I <br /> jl �]Inspection Date O '-, Z � <br /> L Jroc.k}'o n C-,A. 95Z.13� <br /> Cit; �e L;?Cosa Time In Time Out _ <br /> Business Rep Title ���: O AM -�� i O AM <br /> iI f <br /> O PM '-I- -- r- --. O PM <br /> I.A1_be..r+o. .2amor.a_ _.—._ .Admrn►. Cttrk. <br /> " --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) '.(Fill all that appy) (Fill all that apply) .*(Fill all that appy). <br /> t 0 Active !Passenger 0 Generator Q Outdoor <br /> - O Q Closed Q Altered <br /> G P$ Latitude _-_�•I _ _-_ _ _ Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> O <br /> Longitude - I I I. Q Planned Q OTR Q End-Use O.Contajner <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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility MENQ5,RCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> Q Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXT) <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 1 CIWMB Enforcement <br /> Q Q 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 In Compliance No Violations <br /> Q 1 Q 1 Other. § <br /> Comments Rou���_i��p�ec'►�'o_r�.r�o_r_mad�li►_is_d�1t$��)1e_w.iny_w as�_o�ed.:_ <br /> a►eali y 1r►as_aPPT ---5�w_asfil�stes_sta[ed_on-sib__�o►�,br y_fase_s Foor n" <br /> ZIC�F� �C11re S1G.__�Q1i1P �r1nS C-I�EMp t�.--Cn:L- 101f1�ie* k,%,o bee-n- <br /> rt +,n� �►e_re_cucailnbl_t;._�yr vl_ev� r,. _.—�oyt.o1 aha-ar�,g a�a�ceos_aC44n ce <br /> Inspection Form Included:Q A Caoq) <br /> Comments Included:Q t" - ' ! i - = '168-3� <br /> Business R SIg ure Phone Numbei _ Ins or's Signat a Phone Number <br /> INSTRUCTIONS ON BACK 7C.)K�j <br /> Incorrect: X A M P L E 62081 <br /> 1 2 3 <br /> ■ White YellowCopy:Operator Pink Copy:LEA ® ■ <br />