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F <br /> Waste Tire Su{ty & Inspection Repor inspection Report Number ■ <br /> ® I1 - 1088129 <br /> state of California <br /> CIWMB Survey Form - Page 1 <br /> CN.lifornia Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A Survey _ - <br /> inspection--- - — - <br /> ction Detail$ <br /> TPID- F — Inspection Type (Fill one) <br /> Site Suffix: 1 - �- G Routine Q Re inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: tr' 1 c� C� C-G UI <br /> ( � Q CHP Q CIWMB Q Complaint Q Educational Visit Q'Other <br /> Business or Facility Name Inspected By Inspector <br /> Car �X C . <br /> Physical Address �l�r!= �!Qr� Lu <br /> street —` -— <br /> Cj Q [�a � <br /> 1 r , ion Date l � � U �j <br /> r C 0 L r) U� �`�StateZInspect <br /> ZIP �Q I Time In � Out <br /> [ � Time O <br /> City { <br /> J� 0 AM <br /> Business Rep Title I— —� 0 PM .. —� 0 PM <br /> Orrl _ <br /> LBusiness Role <br /> - Storage TypeOperational Status Tire Type <br /> (Fill all that apply)' (Fill all that aPPIY) (Fill all that apply) <br /> (Fill one only) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> .� �D Q Closed Q Altered <br /> 'GPS Latitude . I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - IF- i 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 ® Other �tC ,� <br /> Part-13 -_,_Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS --- <br /> V A HAULING AND MANIFEST REQUIREMEN7anifw, <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration anrt of Tires <br /> Q 1 Q PRC§42953-Contracts with Registered Waste rs. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 Responsible Entities Complyinifesting Requirements DateQ Q 14 CCR§18459.1 -Tire Program IDNumber fro (Required for NOV or EXT) <br /> Q Q14 CCR§18459.2.1 -Submittal of Comprehensis within 90 daysQ Q14 CCR§18459.3-Retention of Comprehensivefor 3 yearsQQ 14 CCR§18460.2-Manifest System Requirementsoregistered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q I, Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities --- <br /> Q 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q I Q Other: -- <br /> Comments _ t c - oQ) 0Wlr7 r rl2�c'0� '. <br /> - o 1-I r1� rl�_ c.i ir�ra .r urrr, -fin_ 1 rie Fh <br /> �yd tlr fa re C.) Qf1_�1�C . CaC4t�l � �2ri f-C�C< ld 1tifQS Y ar_ 2�r - <br /> S eVe �or (1 . lklhCr 11ce cr dtcc -- s:-Jr °r G i M`�c, cr tai F�unrll►r,�, ;� <br /> (�v.u1 t~rtt rtoc1 t tS_ � 1�eC��m— ted ter,ctLOA, T <br /> � <br /> x. <br /> Inspection Form Included: QI 1 <br /> A. <br /> Comments Included: QI <br /> -. <br /> Rules Rep°s Signature Phone Number In a or's Signature, Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />