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Waste Tire Su. ,y & Inspection Report ,ispection Report Number <br /> State of California <br /> CIWMB 181e ) Survey Form - Page 1 11 - 1088228 <br /> California Integrated WaststManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile_ j Inspection Details <br />} TPID- i i I Q ' Inspection Type (Fill one) <br /> Site Suffix: T4T5- � -I I Q Routine Q Re-inspection Q Referral Observation <br /> Local -1- If Referral,choose referral type(Fill one) <br /> Identifier: S ci 1r1 -1 O U1 Count 9 U n <br /> '� I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> Physical Address <br /> Kr stican Lucas I <br /> - <br /> Street <br /> Inspection Date U 8 <br /> i Stuck+on Cry CJSZoS I V <br />' City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> • O PM �_ O PM <br /> Soe Med " s QnG cle r —T -- <br /> 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 /> 3 <br /> 0 Active Q Passenger (n Generator Q Outdoor <br /> GPS <br /> Latitude LSI • O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck 1t1/A <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that app" ' - <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 1'1,�A <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other ��t CIA j C UIr 14-1r] <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 Date m / m / m <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 EXT) <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 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 Q In Compliance - No Violations <br /> Q Q Other: § ------- -- -- -- -.—_ d S 1 <br /> Comments 1-"" <br /> -,�rr -TneCA n 1,.:, a+>` 1'1 d UZt'j_ <br /> FGtcA i-��cl o( : o cry- Aa r-e *\T e:5, can-s� ,_ _��:,�n _W r, `Ti <br /> i re ci <br /> _ e_16117YN,s GA irttLk $ �Or k\l `���_ ser V) C r� rerncayes <br /> 7' \few t.,. `,Zn V12ed CA ETP m00 vP, h c _f rt tG�r�ec� <br /> i ) <br /> Inspection Form Included �,. <br /> Comments Included. QTurr/ y61Business Rep's Signature Phone Number I p ctor's SignaPhone Number <br /> — 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � V 1 E 70 A ! L 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />