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= Inspection Report Number <br /> Waste Tire Su .y & Inspection Report* <br /> State of CaliforniaCWMB T 11088146 <br /> California Integrated 1Waste 81 eManagement Board Survey Form - Page 1 I + <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- I � : Inspection Type (Fill one <br /> Site Suffix: � s - L(�_' ®Routine Re-inspectionOO Referral O <br /> Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: G or) TOaq U1Y1 CoUnfiy O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I ' I �rl�AkQn LLiCgI <br /> I v010 Avr por+ Wcxu I <br /> Street <br /> Inspection Date 7-7 F3Fol <br /> / [OD8 <br /> I 15'racm0n CA 9152-0,61 <br /> .State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM —r 0 AM <br /> Erv\%'orr-en�q, 0 PM 0 PM <br /> eire <br /> Incolr) Coord►rNCAC'r Operational Status Tire Type Business Role Storage Type <br /> ount(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I I A <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> Latitude O I 0 Closed 0 Altered <br /> GPS 0 Hauler Q Indoor <br /> I l O O Inactive 0 Truck <br /> Longitude - I O Planned 0 OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government O Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other -�r1 t�qT .��e�.SC�Q`_CWG, � qtf <br /> -- Q <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notic�Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 10 0 Other: § { �.�:. <br /> Commentsflk ► 1S iCr & `►o rl %&T-'f on-ywa' -i"hy-s date _ 14 -�o 1 l a v')Ing , SUS n o f d— <br /> �c c� ► ..yes tyaSt#_ Re cover u �ar- ,..�a �i re remaYg�. Q <br /> man&esAS ave b-eernd 4 kjere e"'k �ab\r �ar vie-wi rq 00on <br />} Le No qta\ gN%ohz, or Afe c n e - <br /> Inspection Form Included: <br /> Business Rep' g�t <br /> 1-=- - <br /> Comments Included: QJJ <br /> e Phone Number ' Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V ti E 9 I A MI P pli 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />