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Waste Tire SAey & Inspection Repo* Inspection p <br /> In1s ection Re ort Number <br /> '.-.. State B California 111088402 <br /> Cgrated Waste <br /> eManag) Survey Form - Pagel 1 <br /> California Integrated Waste Management Board Y �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details` <br />} TPID- �, Z O I Inspection Type (Fill one), <br /> Site Suffix - <br /> ^� _ m 0 Routine 0 Re-inspection Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S ckrt -1 UAC. L41' <br /> 1 n C o t.A n+u <br /> J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or <br /> Facility Name Inspected By Inspector <br /> Physical Address Kr 1:st ic,n L_U <br /> Zy a C U rnmer C 2 S� • _ <br /> Street f•--- <br /> Inspection Date , Q Q 3 0 <br /> 1 Lod A �-CZyO , <br /> I City Statr, � <br /> _.. ---. —._.__—.—... -----...- -._ '_ -- _,— Time a In Time Out <br /> jd0'c c�cl¢ode <br /> �, <br /> Business Rep Title AM0 AM'] <br /> _ 0P � 0P <br /> - -- ,_,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 /> j 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude ® Closed 0 Altered <br /> . 0 Hauler 0 Indoor <br /> -- 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 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 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice 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/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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> No -4 „res ab�eryed on-site -}-1r� o�zrca� I�nS were never_ <br /> conducets oC a-110 n : S1�e Is oakrcAed _ y alp Elec�r_I_c c <br /> �rdQp)zx)de-nr e\ec.�YO carp},`G(z.A-oC,- 9CCLC) emend +0 cicSe_ TP1D <br /> 14 <br /> 131-79 WT'MS. <br /> Insction Form Included: 0 — --- -- ------_-- - �,,,e"ry <br /> k <br /> ywacat tj..,) -av-.3t ' x tit>t> <br /> meets Included: 0 <br /> Business Rep's Signature Phone Number h-ts door"s Signature ` Phone Number <br /> _ <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X '�A , p 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />