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Waste Tire SJ&y & Inspection Rep'0 re <br /> Inspection Report Number ■ <br /> 3�7.ZZ State California 11 - 1088237 <br /> aEA CIWMBB 181( e ) Survey Form ' Page 1 �_ <br /> California Integrated WasttManagement <br /> Waste Management Board _.... .... - - .. -. _. <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile '_li ��- Inspection Ddtat[s <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 7 ' <br /> ��� m"� t'' ` Lj j 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: To n u n C U <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By [___1L9_.L1_1 <br /> Inspector <br /> o �E no o d5Physical Address - L3 ,LC_� I-1�r <br /> Street <br /> 1 UU Inspection Date tl Q <br /> City..,_L...O��Y1 — _ . Sfafe 5�3 OZiP le I Time In — Time Out — <br /> Business Rep Title O AM Q AM <br /> O <br /> �( L►� o PM �. PM <br /> , <br /> L1 �1 M 0 08LLI : ��s U tT t.t- "1M <br /> Operational Status Tire Type Business Role Storage pe <br /> � <br /> tr rfi (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply)' <br /> , (� <br /> ® Active Q Passenger q Generator Q Outdoor <br /> ,// k e •viii'"�ti",.. '� u��/ltd;�/'x,✓"l lhwxr 'F FY lydi.0�3�+.,'y��'�'l'�`m '�"e'�P��'�., t r;.r� C' '. <br /> Latitude H <br /> I�� I - --- <br /> Q Closed Q AlteredGPS 1 Q Hauler Q Indoor <br /> t� Q Inactive Q Truck <br /> Longitude - , ' Q Planned Q OTR Q End-Use Q Container <br /> I <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 Other [Dl,} ( 113 L4i)U'nW.O(C S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / <br /> 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 1 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Rotn-hnk tnsT"c_tton r �`c,r mA �_-�h►� date i1,e �n��oty►�4, _SUS <br /> naffed No -��rc: Ure tare cin-sl+e , "FGLI 11 �a �_�_ �_11�c�n t)c�u -T%Ye <br /> cc �� <br /> 'S rl�C\0 6 7=YlH � -- y- �1 Tvr �. 011 <br /> �e.. `i' _ m ca n <br /> �erv�ce Loa_te z4Iy-e-1 cy)ovCA L, <br /> Inspection Form Included-' <br /> Comments Included. <br /> -Business Rep's Signature Phone Number Ins ector's Signature ' tl <br /> /�, 62081 <br /> INSTRUCTIONS ON BACK Coi"rect:0 Incorrect: ; vii 'V_? E X A V, Q-' I_i L. i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />