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Waste Tire Su. ley & Inspection Reporl,. Inspection Report Number <br /> r rni Stateof ed Waste Management Board CaliforniaNew Q4104 <br /> CIWMB 1131 , <br /> California IntegrateSurvey Form - Page 1 13 10 2 8 8 81 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection n � -5 � � _ ® � Inspection Type (Fill one) <br /> Site Suffix: ,o( ® Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (��(�(,�� ��� O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> , Inspected By Inspector <br /> 9c)e�� Tru_r J 0oK.� <br /> Physical Address e � . <br /> 6-0 51-D arpevd4r <br /> Inspection Date � "'�, I 3 � I <br /> Time In ~,! Time Out <br /> Business Rep, y/� Title <br /> �� 0 AM 0 AM <br /> �IUQ�Q✓— Sl Al 0 PM 0 PM <br /> 1 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE) 5—D <br /> 0 Active Q Passenger (a Generator ® Outdoor <br /> O Q Closed Q Altered cov-M�e� <br /> GPS Latitude Q Hauler O Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude _ O Planned O OTR O End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair • Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O Other <br /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT.STATUS l <br /> fV Ai HAIJLINt3 RIND MAN IRST.REQU[REM E�IT$ Q Notion Of Violation <br /> O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956- Registration/Decal in Vehicle m m m <br /> O O 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements date <br /> 0 O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire T 18459.3-Retention of Manifest Forms and Tire Tri o for 3 ears days i' T .(Required forNOVor� <br /> 14 CCR n Los within 90 da <br /> Ql0 § p 9 y <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Roferred CIWMB Enforcement <br /> O O : 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> O ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in 0 g0p)lanca ,Ho Violations <br /> O O Other: -- <br /> Comments IA)aste I Tres 6wt _ IAC S�` .- �� fic, Co T,-Kc I Ireff,N0 f il-— <br /> Pm1 m Ave, Modest o a IllA 1K �vr Monte 4-S <br /> �li�vUec�� Mc Co a �sz7 ,�� a s Siris u��t�� ►ree_aI t� V'eiti►e,l . A,'Pa of c eef <br /> d f� <br /> y 1� <br /> r1l D#nO on a I I m ah i Fes is , pi4 t I-P) cI I man i f-es45 ce_-tca(n <br /> 'Inspection Form Included: <br /> p O ��� <br /> Comments Inc)uded: Q <br /> Business ep' Signature Phone Number I s ctor's t nature T Phone Number <br /> INSTRUCTIONS ON BACK Cbrr191Ct. ' ` Irtc0rrea#y ( N �i�r � P; lE �x c L3J 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA re <br /> 1161 <br />