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Waste Tire & Inspection Re Inspection Report Number <br /> ■ <br /> :. V State of California ! � <br /> CIWMB181(New 04/04) Surve`, Form Pa e 1 I 1 1088184 <br /> California Integrated Waste Management Board J g _ <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> - - <br /> Business Profile Inspection Details <br /> I TPID- LJ r inspection Type (Fill one) <br /> Site Suffix: ! t I �7 y Z U ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local L�J If Referral,choose referral type(Fill one) <br /> Identifier: '=� � � I-t 1 Pl C.,U�at"! <br /> _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address — _ <br /> L � I CG S <br /> r►stt��n L —P <br /> 1 0 1333 S . Gomco wx Rd • — <br /> Street ---- _._ <br /> Inspection Date <br /> ,State ZIP Code Time In Time <br /> a Out _ <br /> Business Rep Title ! Q AM Q AM <br /> Q PM —I —._ QPM <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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude —m Closed Altered <br /> GPS I �4 Q Hauler Q Indoor <br /> p——tT ® Inactive 0Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) 71 <br /> New Tire Dealer Auto Repair Trucking Fleet Government Retreader Dismantler Tire �Derived <br /> Fuel t <br /> �. <br /> 11 <br /> 0 0 P 0 9 0 0 0 re Derived Fuel I <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 ® OtherC C)n`Y.+f u_C�I oY1 C( r✓i�r_ y <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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 I Date 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 1 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 <br /> 0 0 Other: § <br /> In Compliance - No Violations <br /> , G <br /> Comments <br /> 5t— u 2, -t IrE_: rLr� a�11 an.- -t _AeP'ro 4, 0,Wn-Q_r E-,ob <br /> F_ 0 :,t.-AteCk -t�)C�} tan Zr-,C. v'., no { ongter actsV1 vPLra-t nil Ute <br /> rA _{i. _ l�1 � ' �. ��-,r;, c_:�(iF_x <br /> r <br /> Inspection Form Included. 0 <br /> Comments Included: 0' Phone In ctorsSignature�;i', , •, Phone Number <br /> Business Rep's Signature r <br /> INSTRUCTIONS ON BACK Correct:W incorrect: X [ ...- A ,� ,� 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />� I <br />