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Waste Tire SAey & Inspection Repo ' Inspection Report Number <br /> m a State of California survey rve Form - Page e 1 Il - 1088282 , <br /> qty CIWMB 181(New nage Y ry <br /> California Integrated Waste Management Board y _.. <br /> Part A- Survey _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details �T <br />} TPID- InspectionLo <br /> ` 1 Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I - (J If Referral,choose referral type(Fill one) <br /> Identifier: SCt o To'a Ain LU Yl+ <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p Y Inspector <br /> Physical Address ke r�7-r U de I n c � <br /> jj _ p 1 1Cr t fi I o n L cy <br /> �_._ r r <br /> L_2g�y 50 _Thor nfio n __ -Street _1_Z'] 1(1:411 <br /> Inspection Date <br /> GQ V� C� 9S(S z ; <br /> city State ZIP Code Time In Time Out, <br /> _ � .. <br /> Business Rep Title 1 : [�_ <br /> O AM Q AM <br /> L QPM �.. . .. —..� PM <br /> n H ,) r n <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)1 <br /> � <br /> t1I* Active <br /> arry Y --�— Q Passenger Q Generator Q Outdoor <br /> Q Closed Q <br /> GPS Latitude ]o Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [-ENFORCE_MENT STATUS _ <br /> HAULING§ AND e <br /> MANIFEST <br /> Hauler Registration trMEN dS <br /> QQ PRTransport of Tires Q Notice Of Violation Q Extension <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§184,5ry9.3-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 § YRequirements - - - - <br /> 14 CCR 18461 -Manifest System _for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (9 In Compliance - No Violations <br /> Other: <br /> Comments <br /> a))6wlr,_- <br /> no T=aC.tilor f e c-,C�I <br /> EUT rrnlnjet+ VUVQ Lern f -�; ,� r Ej I �jerc <br /> r V_I' ,j >n<-i% (r, (A n <br /> Inspection Form Included: Q <br /> Cod-narrerlts included: Q <br /> Btasiness Rep's Signature Phone Number Ins ector s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: Is A 1A p L f , 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />